A TABULAR HANDBOOK 



AUSCULTATION AND PERCUSSION. 



iFor ^tufcntts ana p&pfictan*. 



HERBERT C. CLAPP, A.M., M.D. 

INSTRUCTOR IN AUSCULTATION AND PERCUSSION IN THE BOSTON UNIVERSITY SCHOOL OF MEDICINE, 
AND PHYSICIAN TO THE HEART AND LUNGS DEPARTMENT OF THE COLLEGE DISPENSARY. 



WITH FOUR PLATES. 



1 Nollem esse medicus sine auscultatione et percussione." 

CORVISART. 










\\J'Jo.JJkko3\ 

<-, 187$ ^0 



BOSTON: 

HOUGHTON, OSGOOD AND COMPANY. 

Cjje Etoetstte Press, Cambrt&se, 

1879. 







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Copyright, 1878, 
Br HERBERT C. CLAPP. 



RIVERSIDE, CAMBRIDGE : 

ILECTROTTPED AND PRINTED BY 

H. 0. HOUGHTON AND COMPANY. 



vP 



PREFACE. 



In the preparation of this little book, I have con- 
sulted the works and compared the views of many 
who have been eminent in the physical exploration 
of the chest, such as Laennec, Avenbrugger, Corvi- 
sart, Piorry, Skoda, Barth and Roger, Walshe, Hope, 
Stokes, Fuller, Grisolle, Bennett, Latham, Flint, Bal- 
four, Hayden, Ziemssen, Fothergill, and Loomis, and 
here desire in a general way to acknowledge my in- 
debtedness to them, as it has seemed impossible to do 
so in the text in each instance. 

Since the illustrious Laennec discovered the art of 
auscultation in 1816, very many investigations have 
been made and much has been written on the sub- 
ject. While on the one hand it is perfectly surpris- 
ing how little the master mind of Laennec left to be 
done, and how many of his descriptions, classifications, 
and meanings of sounds still remain unimproved upon 
in spite of sharp criticism, yet on the other hand, as 
would naturally be expected, other experimenters 
since have discovered new facts, and by a wider ex- 
perience have been able to point out more or less 
error here and there in the works of the father of 
auscultation. I have endeavored to give, arranged in 
tabular form, a condensed summary of the most au- 
thentic observations down to the present time. 



IV PREFACE. 

As to the theories of the mechanism of the produc- 
tion of some of the sounds, there has been a great 
deal of controversy, in which Skoda with his " con- 
sonance " and " tension " and other theories has taken 
quite a prominent part. Those theories have been 
given in the following tables which seem most rational 
and which are at present most generally accepted. 

In the nomenclature of the physical signs, care has 
been taken not to use those terms which merely ex- 
press somebody's theory of their mode of production. 
Skoda's " consonating rale," for instance, is a very 
ill-advised term, as the theory of consonance is far 
from being universally accepted, and no one who re- 
jects the theory would like to use such a term. 
Even the common term " mucous rale " has been 
made to give place to the much more expressive 
" bubbling rale," which does not imply that it is 
always caused by mucus, but leaves room for its pro- 
duction sometimes also by pus, serum, softened tuber- 
cle, etc. 

To avoid confusion, and for the convenience of 
those who may have become familiar with some par- 
ticular authority, many of the synonyms have been 
added in small type in parentheses. 

Tn determining what classification to follow, it has 
been thought desirable to avoid the excessive and 
complicated .refinements of some authors, without, on 
the other hand, losing sight of the necessity for suffi- 
cient thoroughness. 

There has been an effort to make the arrangement 
of material in the following tables so systematic, that 
any special point needing investigation can be imme- 
diately referred to, without a tedious and laborious 



PREFACE. v 

search through many pages and perhaps many vol- 
umes. The condensed tabular arrangement will be 
found especially advantageous also in differential di- 
agnosis, as it brings into such close juxtaposition in- 
formation which is usually widely scattered, rendering 
comparison easy, point by point. 

Studied in connection with Chapter IV. of Da 
Costa's excellent work on Diagnosis, with its graphic 
descriptions and convenient, helpful diagrams, these 
tables will probably furnish the student with all that 
is really necessary in the majority of cases coming 
under observation. If, however, he desires to make 
a special study of the subject, he is referred to the 
two large and valuable treatises on the " Diseases 
of the Respiratory Organs" and "Diseases of the 
Heart," written by Dr. Austin Flint of New York, 
who is probably the greatest authority on the phys- 
ical diagnosis of such diseases in this country, and to 
whom I desire to acknowledge myself especially in- 
debted. It should be remembered, however, that the 
pathology of these works is not quite up to date. 

It is also hoped that this handbook may be found 
useful by physicians in active practice. It is hardly 
to be expected that practitioners who do not make a 
specialty of lung and heart diseases, even if they 
have at some time carefully studied into the subject, 
and have been well posted, can retain in their memories 
for immediate use at all times every point necessary 
for a delicate physical diagnosis. If the case be at 
all obscure, they feel the necessity of consulting some 
authority. In such emergencies, the busy doctor may 
appreciate such a time and labor saving contrivance 
as the present. It often needs only a word here and 
there to revive memories of extensive reading. 



vi PREFACE. 

It is very doubtful if at this late day any well edu- 
cated physician could be found to despise the value 
of auscultation and percussion as aids to diagnosis. 
Such a contempt would at once stamp the man who 
showed it as an ignorant pretender. But there are 
many who do not feel thoroughly at home in this 
branch, and on account of too slight practical ac- 
quaintance with it, and lack of time or inclination 
for a laborious research into its theory, prefer to trust 
for the most part to the symptoms alone rather than 
to the uncertainties (to them) of physical signs. 
Here most truly " a little knowledge is a dangerous 
thing." For if the practitioner, finding jerking res- 
piration, for example, in a given case, knows that 
jerking respiration is a sign of phthisis, and does not 
remember that it may be a sign of several other dis- 
eases too, and on the strength of this sign alone diag- 
nosticates the case as phthisis, it would, indeed, be far 
better for him to have known nothing whatever of 
auscultation and percussion, and to have been guided 
entirely by the symptoms. It is such partial knowl- 
edge, to say nothing of the utter ignorance of others, 
that has to some extent brought auscultation and per- 
cussion into disrepute in certain places. 

It is very desirable to have a proper appreciation 
of the comparative value of physical signs and symp- 
toms, without enthusiastically overestimating either. 
He who trusts to symptoms alone for his diagnosis of 
heart and lung diseases will very, very often be led 
astray. On the other hand, the mistake may be made 
in the opposite direction of placing too exclusive reli- 
ance on physical signs alone. In fact, they must be 
taken together and complement each other. If they 



PREFACE. vii 

are, and proper attention is paid to the history of 
each case, and also to its well-known pathological 
laws, an accurate diagnosis can be made in the great 
majority of instances. 

When speaking of heart diseases, Da Costa says : 
" A knowledge of the physical signs is the solid 
foundation, without which any structure that may be 
reared will soon tumble to pieces." 

In fact, the symptoms of heart disease are compara- 
tively insignificant. Quite so much cannot be said of 
the comparative value of signs and symptoms in lung 
diseases ; but even here the great importance of the 
former is attested by the immense strides which have 
been made in the diagnosis of such affections since 
the discovery of the present methods of physical ex- 
ploration, which would have been utterly impossible 
before. 

The plates have been reproduced (with slight alter- 
ations), by the " direct transfer " process, from the 
" Handbuch und Atlas der topographischen Percus- 
sion," by Professor Weil of Heidelberg, published 
at Leipzig in 1877. 

H. C. CLAPP. 

544 Tremont Street, Boston, October 3, 1878. 



CONTENTS. 



PAQB 

INTRODUCTION xi 

PART I. 

TABLE NO. 1. 

Respiration in Health. 

Vesicular, puerile, senile, and tracheal or laryngeal .... 20 

TABLE NO. 2. 

Respiration in Disease. (1.) Abnormal Intensity. 

Exaggerated, feeble, and suppressed 22 

TABLE NO. 3. 

Respiration in Disease. (2.) Abnormal Rhythm. 

Jerking respiration and prolonged expiration 24 

TABLE NO. 4. 

Respiration in Disease. (3.) Abnormal Quality and Pitch. 

Bronchial, broncho-vesicular, cavernous, and amphoric .... 26 

TABLE NO. 5. 

Rales. 

I. Tracheal and laryngeal ; dry and moist 30 

II. Bronchial ; dry (sonorous and sibilant), and moist (coarse and fine 

bubbling and subcrepitant) 30 

III. Vesicular ; crepitant 34 

IV. Cavernous; gurgling 34 

TABLE NO. 6. 

Morbid Pleural Sounds. 

Friction sounds, metallic tinkling, and splashing 36 



CONTENTS. 



TABLE NO. 7. 

The Voice in Health. 

Tracheal or laryngeal voice and whisper, normal thoracic vocal reso- 
nance and fremitus, and normal bronchial whisper .... 40 

TABLE NO. 8. 

The Voice in Disease. 

Suppressed, diminished, and increased vocal resonance and fremitus, in- 
creased bronchial whisper, bronchophony and whispering bron- 
chophony, cavernous whisper, amphoric voice and whisper, pec- 
toriloquy and whispering pectoriloquy, segophony, and metallic tink- 
ling 42 

TABLE NO. 9. 

Percussion Signs. 

Normal vesicular resonance, flatness, dullness, and tympanitic, exag- 
gerated, amphoric, and cracked-metal resonance .... 46 

PART II. 

TABLE NO. 10. 

The Physical Diagnosis of Diseases of the Lungs. 

Acute and chronic pleurisy, empyema, hydrothorax, pulmonary cedema, 
pneumo-hydrothorax, pneumothorax, emphysema, asthma, bron- 
chitis, capillary bronchitis, plastic bronchitis, croupous pneumonia, 
catarrhal pneumonia, chronic pneumonia, acute miliary tuberculo- 
sis, phthisis, dilatation of bronchi, carcinoma of lung, and intra-tho- 
racic tumors, especially aneurism 54 

TABLE NO. 11. 

The Physical Diagnosis of Diseases of the Heaet. 

The healthy heart, pericarditis, endocarditis, hypertrophy of the left and 
right hearts, dilatation, valvular lesions of the left heart (aortic ob- 
struction and regurgitation, and mitral obstruction and regurgita- 
tion), and of the right heart (pulmonic obstruction and regurgita- 
tion, and tricuspid obstruction and regurgitation), fatty degenera- 
tion, and* cardiac neuroses 78 



INTRODUCTION. 



Pathognomonic physical signs are exceedingly 
rare. It is not true that each disease has belonging 
to it one or more individual signs like labels, which 
are always associated with it and no other. The no- 
menclature of diseases is not so rigidly prescribed by 
nature as it would be in such a case. Physical signs, 
instead of representing individual diseases, represent 
merely physical conditions which may be common to 
several diseases. For instance, dullness on percus- 
sion, bronchial or broncho-vesicular respiration, bron- 
chophony, and increased vocal fremitus in combina- 
tion would indicate solidification of the lung, but 
they do not tell us on what the solidification depends. 
It may be pneumonia, it may be phthisis, it may be 
collapse of pulmonary lobules, it may be lung tissue 
compressed by a pleuritic exudation. The disease, 
the particular cause of the solidification, we have to 
reason out from the presence or absence of other 
physical signs, from our knowledge of pathology, and 
from the history and symptoms of the case. 

Before beginning the study of auscultation and per- 
cussion, the student should be thoroughly posted in 
the anatomy and physiology of the organs of respira- 
tion and circulation. Then naturally follows the to- 
pography of these organs. As an aid in constantly 



xil INTRODUCTION. 

keeping before the mind this topography, which is of 
very great importance, especially in the diagnosis of 
heart diseases, the plates have been added to this vol- 
ume, and should be carefully studied and often re- 
ferred to. The details of pictorial illustrations are 
easier for most persons to remember than long verbal 
descriptions, no matter how accurate they may be. 

For convenience in localizing, recording, and com- 
paring signs, the surface of the chest has been mapped 
out into anterior, lateral, and posterior regions, right 
and left, as follows : — 

Anteeiorly — The supra- clavicular region, extend- 
ing from the clavicle upwards a distance varying from 
half an inch to an inch and a half; clavicular, the 
space occupied by the clavicle ; infra-clavicular, be- 
tween the clavicle and the third rib ; mammary, be- 
tween the third and sixth ribs ; infra-mammary, be- 
low the sixth rib ; supra- sternal, the hollow space 
above the sternum ; superior-sternal, under the ster- 
num above the third rib ; inferior -sternal, under the 
sternum below the third rib. 

Laterally — The axillary region, having for its 
lower boundary a horizontal extension of the lower 
boundary of the mammary region ; infra-axillary, be- 
low this line. 

Posteriorly — The scapular region, the space oc- 
cupied by the scapula, extending also to a horizontal 
line drawn through its lower angle ; infra-scapular, 
below this line to the twelfth rib ; inter-scapular, be- 
tween the inner margin of the scapula and the spinal 
column. 

It is very essential that the healthy sounds of aus- 
cultation and percussion should become thoroughly 



INTRODUCTION. xin 

familiar to the student before lie spends much time 
on the morbid sounds. And yet, there is a constant 
tendency to hurry over and neglect the former for 
the sake of getting at the practical work of the lat- 
ter. No one would undertake to tune a piano without 
being so familiar with the true tones that he could 
recognize the least departure from them. Very often 
in the most important cases brought to the physician, 
where there is the greatest desire for information, as, 
for example, in the detection of the very beginnings 
of phthisis, the deviations from the normal sounds are 
so slight as to be entirely disregarded by those who 
do not know by practice exactly what the normal 
sounds in the different regions of the chest ought to 
be. And even where one thinks he knows this, con- 
stant reference to the healthy standard is necessary. 

Auscultation is said to be immediate when the un- 
assisted ear is applied to the chest of the patient, and 
mediate when a stethoscope is used. Both methods 
are in use, and it is very desirable to become practi- 
cally familiar with each. Some physicians think that 
they can hear as well with the unassisted ear as with 
the stethoscope ; but the great majority of those who 
have much to do with auscultation give a very de- 
cided preference to that instrument. Those who have 
used a stethoscope for any considerable length of 
time very seldom like to give it up. It is often pref- 
erable on grounds of delicacy when examining lady 
patients, and the avoidance of too close contact which 
it insures is certainly pleasanter to the examiner, 
when the patient happens to be at all uncleanly. 
Besides, it can be applied to certain places (such as 
the hollow over the clavicle, for instance) to which it 



xiv INTRODUCTION. 

is difficult or impossible to adjust the ear. With it, 
also, particular sounds, which we may wish to locate 
definitely and to hear as far as possible unmixed with 
others (as, for instance, valvular murmurs), can be 
circumscribed. With Cammanns double or binaural 
stethoscope, which is the best, the sounds are intensi- 
fied and made more distinct, and some are rendered 
audible which would be inappreciable to the unassisted 
ear. At first, until one gets accustomed to it and 
learns how to use it, there is a disagreeable humming 
or buzzing which is very confusing, but this soon 
passes off. The pectoral extremity should be closely 
applied with moderate pressure, and the edges should 
fit the skin exactly all around, not being tilted up at 
one side to allow the air to enter. The room should 
be quiet and there should be no friction between the 
stethoscope and the clothing. Stiff hair on the chest 
under the instrument often occasions a sound which 
might be confused with the crepitant rale. Beginners 
almost always get the ear-pieces in the wrong way. 
They should follow the direction of the auditory canal. 
The stethoscope should be applied to the bare skin. 
When the unassisted ear is used, it is pleasanter to 
have over the chest one thickness of soft cloth, like 
the undergarment, or a towel. When an accurate ex- 
amination in a doubtful case is desired, it is utterly 
impossible to make it without removing the most, if 
not all, of the clothing from the chest ; and the man 
who, in such a case, gives two or three raps, puts his 
head down over a stiffly starched shirt or creaking 
corsets or rustling silk, and then solemnly and oracu- 
larly pronounces an opinion, is generally acting igno- 
rantly or dishonestly by his patient. It might almost 



INTRODUCTION. xv 

be said that if the intra-thoracic noises are all so loud 
that they can be heard above the noise which the 
outside clothing makes, it is not of very much im- 
portance to the diagnosis that they be heard at all, 
for in such conditions the symptoms are generally 
enough. The great danger in listening through all 
the clothing is that of not hearing (or mixing up) deli- 
cate and important signs. In many cases, where the 
problem is to decide whether or not phthisis is pres- 
ent, it is sufficient to unbutton the upper part of the 
clothing and turn it aside so as to expose the infra- 
clavicular regions for examination, as phthisis gener- 
ally attacks these regions first. But even here, if no 
deposit be found, particular thoroughness demands a 
further search. 

In immediate auscultation it is advisable to close 
one ear with the finger to exclude outside noises, 
and particularly when studying vocal phenomena. In 
the latter case, besides, the patient should turn his 
head to one side and put his hand up to his mouth to 
prevent the auscultator's confusing his voice com- 
ing directly from the mouth with the vocal resonance 
coming through the chest. The auscultator should 
also avoid stooping over too much when listening, as 
the congestion of blood caused by such a position 
dulls somewhat the acuteness of hearing. Unless too 
weak, the patient is best examined in the sitting post- 
ure, with his arms hanging down for the anterior 
portion of the chest, raised and crossed over his head 
for the lateral regions, and crossed with the body bent 
forwards for the posterior regions. Generally he has 
to be instructed to breathe harder than usual, and often 
has to be shown how to breathe properly. In children 



XVI INTRODUCTION. 

it is easy to judge of the vocal resonance when they 
cry. Finally, one side of the chest should be con- 
stantly compared with the other, portion by portion. 

Percussion, as a method of diagnosticating disease, 
was discovered by Avenbrugger, whose researches 
were published at Vienna in 1761. They attracted 
but little attention, however, until Corvisart fifty 
years afterwards translated them into French and in- 
troduced the practice into the French hospitals. Per- 
cussion, like auscultation, is both immediate and medi- 
ate. The immediate (which was the only method 
known to Avenbrugger and Laennec), where the chest 
was struck directly by the fingers, is now never re- 
sorted to, having been entirely superseded by the 
invention by Piorry of mediate percussion, which 
interposes some solid substance, called a pleximeter, 
between the chest and the percussing agent. For 
this purpose, little plates of ivory or wood with han- 
dles have been used, or a flat piece of common elastic 
India rubber. The best pleximeter, however, is a 
tapering cylinder of hard rubber or gutta-percha 
about two inches long, flanging at each end, one cir- 
cular end-piece being smaller than the other for ap- 
plication to the intercostal spaces and supra-clavicular 
regions, the body of the cylinder (which is applied 
to the chest at right angles) making an excellent 
handle. The best percussor is a little hammer with 
a hard rubber rod or handle which can be detached 
from the head, which is made of brass and tipped 
with soft rubber. Most physicians use for a plexime- 
ter the left middle or forefinger, with its palmar sur- 
face applied to the chest, and for a percussor the right 
middle or forefinger (or both together), bent so as to 



INTRODUCTION. xvn 

strike at a right angle. Although it takes considera- 
ble time and practice to become really expert in per- 
cussing with the fingers, much more than with the 
instruments just described, yet everybody should 
learn this method, as it is a very valuable one, and 
the instruments cannot always be at hand to be de- 
pended upon. Where one has a great deal of per- 
cussing to do, however, he generally prefers the in- 
struments, as so much pounding on the back of the 
finger used as a pleximeter is apt to make it sore. 
Besides, the instruments bring out the sounds more 
distinctly, especially for purposes of demonstration to 
others. 

Unless the patient is really obliged to lie down, he 
should be percussed in the sitting or standing posture, 
with his arms placed as already described for aus- 
cultation, the examiner being directly in front. The 
two sides should be percussed at the same stage of 
respiration, as the expanded lung occupies more room, 
pushing down the liver and spleen and pressing more 
in front of the heart ; the difference between a full 
inspiration and a deep expiration being very consid- 
erable. 

Since we draw our inferences as to the condition 
of the lungs from the comparative sound in differ- 
ent parts of the chest rather than from the absolute 
sound, this varying somewhat in different individu- 
als, it is important to strike, immediately after each 
other and with the same force, portions on one side 
which correspond as nearly as possible to portions 
on the other side. Four or five raps in succession 
are best, and should be quick and sharp rather than 
slow and heavy. More forcible blows are required to 



xvm INTRODUCTION. 

elicit the sounds of deeply seated than of superficial 
portions. The finger or pleximeter should be applied 
firmly on the spot to be examined, and with precisely 
the same amount of firmness on the corresponding 
spot on the other side. 

The pressure should be sufficient to condense the 
soft parts on the outside of the chest. Percussion 
should be performed by a movement of the wrist 
alone, the arm and forearm remaining motionless. It 
would be well for the beginner to commence by per- 
cussing the right infra-clavicular region in a healthy 
subject, and to contrast the vesicular resonance found 
here with the flatness of the liver. Next he might 
try to bring out the proper sound of that part of the 
liver which lies underneath the lung. After becoming 
practically familiar with all the sounds in the different 
regions in health, he can try, as a final test of his 
powers, the deep cardiac space. If he can bring out 
the sounds of that satisfactorily, he may consider him- 
self proficient. 

Heart-sounds. — In health there is no difficulty in 
telling by auscultation which is the first and which 
the second sound of the heart by the rhythm and 
the distinctive characters of the two sounds at the 
apex and base ; and generally it is easy to decide the 
question in the same way if the heart is diseased, 
when it is desired to know whether a murmur is sys- 
tolic, presystolic, or diastolic. But sometimes it is 
impossible or difficult to do so. In such cases, if the 
apex-beat can be felt, this being synchronous with the 
first sound, the problem is at once solved. If it can- 
not be felt, the radial pulse will settle the point, or 
still better the carotid, which is more nearly synchro- 
nous with the first sound of the heart. 



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PART I. 

PHYSICAL SIGNS. 



20 



AUSCULTATION AND PERCUSSION. 



TABLE NO. 1. 



VARIETIES. 


character of the sound. 


Vesicular Respiration. 
(Pulmonary.) 


Inspiration. 

A soft, diffused sound of a breezy character, grad- 
ually developed and continuous. Increased in in- 
tensity with the rapidity and force of respiration, 
and prolonged by a full inspiration. Low pitch. 

Expiration. 

Not vesicular, but feebly blowing in quality. 
Pitch lower and intensity much less than in inspi- 
ration. Usually not more than one fourth the 
length of inspiration, and absent in about one 
third of the cases. No interval between inspira- 
tion and expiration. 


Pcerile Respiration. 


The same quality, pitch, and rhythm as the (pul- 
monary) vesicular murmur, but exaggerated or 
intensified in degree. 


Senile Respiration. 


The same as the vesicular respiration, except 
that the intensity is diminished and the expiration 
relatively more developed and longer. 


Tracheal or Laryngeal 
Respiration. 


Inspiration. 

Tubular in quality, loud, dry, and hollow. 

High pitch. An interval between inspiration 
and expiration. 

Expiration. 

Tubular in quality. Uniformly present. As 
long as the inspiratory sound, and generally 
longer. More intense and higher in pitch. 



AUSCULTATION AND PERCUSSION. 



21 



RESPIRATION IN HEALTH. 



HOW PRODUCED. 



Inspiratory Sound. 

1. "By vibrations excited in the in- 
ward current of air by its friction 
ngainst the walls of the air passages. 

2. By the obstacles presented by the 
subdivision of the bronchi ; " and 

3. By the forcible separation of the 
walls of the pulmonary vesicles, which 
after the previous expiration have be- 
come more or less adherent on account 
of their natural moisture. 
Expiratory Sound. 

Simply " by the vibrations excited in 
the expired air by its friction against 
the walls of the air-passages." 



USUAL SEAT. 



All parts of the chest. There are 
variations in the intensity of the mur- 
mur in the different regions of the chest, 
there being more in the infra-clavicular 
and inter-scapular and in the axillary 
and infra-axillary regions than in the 
mammary and infra-mammary regions, 
and least of all in the scapular region. 

Sometimes there is r.lso a slight disparity be- 
tween the two sides, in which case the vesicu- 
lar quality is more marked and the pitch lower 
on the left than on the right side , in the latter 
there being a slight approach to the character 
of broncho-vesicular respiration (Table No. 
4), i. e., expiration a little longer with higher 
pitch, and inspiration a little shortened. 



The greater intensity of the murmur 
is owing to the greater freedom of the 
action of the lungs in early childhood. 



In children, in all parts of the chest 
where the ordinary vesicular respira- 
tion is audible. 



The change is owing to the attenua- 
tion of the walls of the air-cells in aged 
persons. 



In old age, in all parts of the chest 
where the ordinary vesicular respira- 
tion is audible. 



By the rush of air through a tube of 
considerable diameter, rough and irreg- 
ular on its internal surface, and possess- 
ing sound-reflecting properties. " The 
higher pitch of the expiratory sound is 
due to the greater contraction of the 
glottis by the approximation of the vo- 
cal chords in expiration." 



In the supra-sternal region, over the 
trachea and larynx. 



22 



AUSCULTATION AND PERCUSSION. 



TABLE NO. 2. - RESPIRATION IN DISEASE. 



VARIETIES. 


character of the sound. 


HOW PRODUCED. 


Exaggerated Res- 
piration. 

(Puerile, supplementary, 

increased, hypervesicu- 

lar.) 


Like the healthy vesic- 
ular murmur in pitch, 
rhythm, and quality, but 
intensified in degree. Iden- 
tical in character with the 
puerile respiration of 
healthy children. 


By the excessive action 
of certain healthy portions 
of the lungs, set up to sup- 
ply the deficiency of res- 
piration in other portions, 
which are destroyed or 
affected by disease. 


• 

Feeble Respira- 
tion. 

(Diminished, weak.) 


" The ordinary vesicular 
murmur, not altered in 
character, but simply di- 
minished in intensity and du- 
ration." 


By any cause which in- 
terferes with and prevents 
the full inflation of the 
lungs. Such as — 

1. An obstruction to the 
passage of air in some por- 
tion of the air tubes. 

2. An obstruction or 
over -distention of the air 
vesicles. 

3. Some restraint on 
the movements of the 
chest. 

4. The respiratory mur- 
mur may be imperfectly 
transmitted to the ear, 
owing to intervening fluids, 
solids, or air. 


Suppressed Respi- 
ration. 

(Absent.) 


No sound is heard. 


By very great obstruc- 
tion to the entrance of air, 
or by the interposition of 
fluid or air in the cavity 
of the pleura, preventing 
the transmission of the 
sound. 



AUSCULTATION AND PERCUSSION. 






ABNORMAL INTENSITY. 



USUAL SEAT. 



Not peculiar to any portion of the 
chest, and not diffused generally 
throughout both sides of the chest, like 
the healthy puerile breathing, but 
limited to certain spots iu the vicinity 
of diseased portions of the lungs, or 
heard all over the healthy lung, when the 
other is diseased. If heard all over 
both lungs, it is to be regarded merely 
as an individual peculiarity and not 
as a sign of disease. 



DISEASES INDICATED. 



Pleurisy. 

Pneumonia. 

Phthisis. 

Vesicular emphysema. 

Apoplectic effusion. 
Carcinoma. 
Spasmodic asthma. 
Pneumothorax. 
Foreign body in bronchus. 
Aneurismal or other intra-thoracic tumors 
pressing on certain bronchi. 



Variable. The whole or a part of a 
lung. 

Feeble respiration, occurring in so 
many conditions, becomes of diagnos- 
tic importance only when associated 
with other phenomena. 



1. Croup ; oedema or spasm of the glottis ; 
inflammatory exudations in the larynx ; for- 
eign body in a bronchus; mucus, serum, blood, 
or pus in bronchus ; swelling of mucous mem- 
brane in bronchitis ; asthma ; permanent con- 
traction of bronchi ; tumors pressing on bron- 
chi, i. e., aneurism or enlarged lymphatic 
gland. 

2. Phthisis, pneumonia, pulmonary oede- 
ma, vesicular emphysema, extravasation of 
blood. 

3. Paralysis of costal muscles or of dia- 
phragm; general debility; permanent contrac- 
tion after chronic pleurisy ; old pleuritic ad- 
hesions ; deformity of chest ; the pain of acute 
pleurisy, pneumonia, intercostal neuralgia, 
pleurodynia, or peritonitis : the mechanical 
interference of ascites, pregnancy, and abdom- 
inal tumors. 

4. Pleuritic effusion, thick layer of lymph 
on pleura, hydrothorax, pneumo-hydrotho- 
rax, tumors, thick layer of fat on outside of 
chest. 



" May occur in any portion of the 
chest, but always limited to one or more 
parts, and usually to the whole or some 
portion of one lung only." 



Same diseases as feeble respiration, 
with this difference, that it indicates 
more decided anatomical lesions. Most 
commonly observed in connection with 
excessive effusions of fluid or air in the 
pleura. 



24 



AUSCULTATION AND PERCUSSION. 



TABLE NO. 3. — RESPIRATION IN DISEASE. 



VARIETIES. 


CHARACTER OF THE SOUND. 


HOW PRODUCED. 


Jerking 

Respiration. 

(Interrupted, wavy, 
cogged-wheel.) 


Both sounds, especially 
the inspiratory, instead of 
being even and continuous 
from their commencement 
to their close, are broken 
into one, two, or more parts. 


1. By some local obstacle 
to the ingress or egress of air. 
Usually the pressure of tu- 
bercular or other deposit, or 
the presence of thick mucus 
in the air passages, or spasm 
of a tube. 

2. By nervousness or shrink- 
ing on account of pain. 


Prolonged 
Expiration. 


The rhythm changed so 
that the expiration is length- 
ened absolutely and rela- 
tively to the inspiration, 
which is generally short- 
ened. 


1. When the air-cells are 
over-distended and have lost 
their natural elasticity from 
this distention or (2) on ac- 
count of deposits in their 
walls, the air has difficulty in 
making its escape. This dif- 
ficulty may be increased in 
the latter case by the promi- 
nences produced by the de- 
posit on the interior of the 
final bronchial ramifications, 
these prominences opposing 
obstacles to the rapid egress 
of air. 



AUSCUL TA TION A ND PER C US S ION. 



25 



ABNORMAL EHYTHM. 



USUAL SEAT. 



1. Limited to a part of the chest, 
usually one of the apices, where it is 
of more clinical significance than when 

2. Generally diffused over the chest. 



1. All over one or both sides of the 
chest, especially the upper parts. 

2. In the infra-clavicular region, es- 
pecially on the left side. 



DISEASES INDICATED. 



1. Incipient phthisis. 
Circumscribed bronchitis. 
Asthma. 

2. Nervousness. 
Pleurisy. 
Pleurodynia. 
Intercostal neuralgia. 

This sound is occasionally observed even 
in healthy persons. 



1. Emphysema 

(if non-tubular and of low pitch). 

2. Phthisis 

(if tubular and of high pitch). 

Occasionally heard to a slight extent on 
the right side of the healthy chest. 



26 



AUSCULTATION AND PERCUSSION. 



TABLE NO. 4. — RESPIRATION IN DISEASE. 



Bronchial 
Respiration. 



(Tubular.) 



Broncho-vesicu- 
lar Respiration 

(Rude, rough, harsh, 

vesiculo-bronchial, tu- 

bulo-vesicular. ) 



character of the sound. 



Inspiration. 

Quality tubular, non- 
vesicular. Intensity vari- 
able, pitch high. Inspi- 
ratory sound shortened ; 
ends before end of inspi- 
ratory act. Rarely ab- 
sent. Can be imitated by 
blowing through a tube 
formed by the fingers and 
palm of one hand. 

Expiration. 

Quality tubular. Pro- 
longed; as long as or 
longer than the sound of 
inspiration and more in- 
tense. Pitch still higher. 
Rarely absent. 



Inspiration. 

The tubular and vesic- 
ular quality combined in 
varied proportions, and 
the pitch raised in pro- 
portion to the amount of 
tubular quality. Dura- 
tion frequently shortened 
at the end. Intensity va- 
riable. Sometimes ab- 
sent. 

Expiration. 

Prolonged. Generally 
more intense than inspi- 
ration. Pitch higher than 
in inspiration. Quality 
according to quality in in- 
spiration. Sometimes ab- 
sent. 



how produced. 



It always denotes consid- 
erable or complete solidifica- 
tion of pulmonary substance, 
either by the addition of 
some morbid material or by 
compression. This involves 
suppression of the vesicular 
murmur. The sound pro- 
duced by the passage of air 
through the bronchi, which 
in health is stifled by the 
vesicular murmur and ren- 
dered inaudible, is now trans- 
mitted to the ear intensified 
by the solidified lung, which 
is a better sound-conductor 
than the healthy lung. 



Being a combination, in 
varied proportions, of the 
bronchial and vesicular res- 
piration, it is produced by 
the same cause as the pre- 
ceding, although not to the 
same extent ; the amount of 
solidification not being suf- 
ficient to extinguish all vesic- 
ular murmur. 



AUSCULTATION AND PERCUSSION. 



27 



ABNOEMAL QUALITY AND PITCH. 



USUAL SEAT. 



In phthisis and pleurisy generally 
in the upper part of the chest. In 
pneumonia generally the lower part 
behind, especially on the right side. 
In other cases variable. 

Being identical with the healthy " Tracheal 
Kespiration," it may be studied in the supra- 
sternal region of a sound person. 



Same as the preceding. A very 
important sign in the diagnosis of in- 
cipient phthisis. 



DISEASES INDICATED. 



Pneumonia. 
Phthisis. 
Pleuritic effusion. 

Collapse of pulmonary lobules. 

Pulmonary oedema. 

Pulmonary apoplexy. 

Carcinoma. 

Hydrothorax. 

Hy d ro - pericardium . 

Aneurism and other tumors. 



Same diseases as the preceding, 
only indicating a lesser amount of solid- 
ification. In the resolution of acute 
lobar pneumonia (croupous), all vari- 
eties of the sound may be heard by 
daily auscultation, from that which 
verges on the bronchial in complete 
solidification, to that which verges on 
the vesicular, which comes with re- 
covery. 



28 



AUSCULTATION AND PERCUSSION. 



TABLE NO. 4, Continued. — RESPIRATION IN DISEASE. 



VARIETIES. 



Cavernous 
Respiration. 



Amphoric 
Respiration. 



character op the sound. 



Inspiration. 

Quality blowing simply ; 
non-vesicular, non-tubu- 
lar. Often mixed with 
gurgling. (Table No. 5.) 

Expiration. 

Quality blowing. Low- 
er pitch than inspiration. 
May be absent. Often 
mixed with gurgling. 

Some recognize also a bron- 
cho-cavernous respiration, 
which, as its name signifies, 
is a combination in varied 
proportions of this and the 
bronchial respiration. 



A kind of musical in- 
tonation like the sound 
produced by blowing 
upon the open mouth of 
a decanter or phial. It 
may accompany either 
inspiration or expiration 
or both. It may be hum- 
ming and of low pitch or 
decidedly ringing and 
metallic. 



how produced. 



Produced by the passage 
of air into and from a cav- 
ity with flacci d walls. 

Absent when the cavity is 
filled with liquid, or when 
the tubes leading to it are 
obstructed. If deep-seated, 
and beneath solidified lung, 
it may be drowned out by the 
loud bronchial respiration. 
Rales also may obscure it. 

It can be imitated by blow- 
ing into a cavity formed by 
the two hands. 



Not caused, like cavernous 
respiration, " by the free circu- 
lation of air within a cavity, 
but by the current of air in 
the bronchial tubes acting 
upon the air contained within 
a cavity." The cavity must 
have more or less rigid walls, 
which do not collapse with 
expiration; it must be of 
considerable size, partially or 
entirely free from liquid con- 
tents ; there must be an un- 
obstructed communication 
(or merely a very thin sep- 
tum) between a bronchial 
tube and the cavity, and the 
perforation must be above 
the level of the liquid, if 
there be any liquid. 



AUSCULTATION AND PERCUSSION. 



29 



ABNORMAL QUALITY AND PITCH, Continued. 



USUAL SEAT. 



Heard over a circumscribed area, 
corresponding to the size of the cavity. 

Being vastly more common in 
phthisis than in other diseases, its 
seat is generally at the summit of the 
chest. 



Generally confined to a circum- 
scribed space, but is sometimes dif- 
fused more or less over the chest. 



DISEASES INDICATED. 



Phthisis. 

Earely in 
Pulmonary abscess. 
Gangrene. 
Cancer. 
Bronchial dilatation. 



Almost pathognomonic of pneu- 
mo-hydrothorax with pulmonary fis- 
tula. Sometimes in phthisis. 

Still more rarely in abscess, etc. 



30 



AUSCULTATION AND PERCUSSION. 



TABLE NO. 5. 



VARIETIES. 


CHARACTER OF THE SOUND. 


RELATION TO INSPIRATION 
AND EXPIRATION. 




Whistling, wheezing, crow- 


Mostly with inspiration. 
Sometimes with both. 


I. Tracheal 


ing, whooping, etc. Most 


AND 


of them are heard without 




Laryngeal 


special auscultation and at a 




Bales. 


distance. 




a. Dry or vibrat- 






ing. 








Bubbling sounds, often 


With both. 


b. Moist or bub- 


called " death-rattles." 




bling. 








Loio-pitched, musical sounds, 


With both or either, es- 




compared to snoring, cooing, 


pecially with expiration. 


II. Bronchial 


buzzing, grunting, humming, 




Bales. 


a note of a bass-viol, etc. 




a. Dry or vibrat- 






ing. 






(l.) Sonorous 






Bales. 








High-pitched, whistling, 


With both or either, es- 




hissing, or clicking sounds of 


pecially with inspiration. 




variable intensity and dura- 






tion and irregular recur- 






rence. Often compared to 




(2.) Sibilant 


shrill musical tones, the cries 




Bales. 


of young animals, the chirp- 
ing of birds, whistling of 
wind through a keyhole, etc. 
Heard with the respiratory 
murmur, or the latter may 
be masked. Loudest in asth- 
ma. 





AUSCULTATION AND PERCUSSION. 



31 



KALES (Rhonchi). 



HOW PRODUCED. 



1. By contraction at 
the glottis from spasm, 
oedema, exudation of 
lymph, etc. 

2. By diminution of 
calibre of tube below the 
glottis. 



By the passage of air 
through mucus or other 
liquid in the tube. 



" By the vibrations ex- 
cited by the passage of 
air through the larger 
bronchi, irregularly nar- 
rowed, either by spas- 
modic contraction of their 
circular fibres," or by 
swelling of their mucous 
membrane, or by the ad- 
hesion of viscid mucus to 
their walls, or by the 
of a tumor. 



Produced in the same 
manner, but in the smaller 
bronchial tubes. 



USUAL SEAT. 



Larynx and trachea. 
These sounds are often 
propagated through the 
bronchial tubes and 
heard in the chest, where 
they may, in a few cases, 
be thought to originate. 
Auscultation of the 
larynx and trachea will 
at once settle the point. 



Larynx and trachea. 



Constantly liable to 
change position. May 
sometimes disappear af- 
ter coughing. They are 
either — 

1. More or less diffused 
over the whole chest ; or, 

2. Confined to one side 
of the chest, or limited 
to a circumscribed space. 
(In phthisis the circum- 
scribed space is gener- 
ally at the summit of the 
chest.) 



Same as sonorous 
rales, with which they 
are frequently mingled. 



DISEASES INDICATED. 



1 . Laryngismus stridu- 
lus. 
Pertussis. 
Croup. 



2. Pressure of a tumor. 

Morbid growths or depos- 
its. 

Cicatrization of ulcers. 

Paralysis of laryngeal 
musclea. 



The moribund state. 

Coma. 

Inability to expectorate. 



1. Asthma. 
Bronchitis. 

2. Circumscribed bron- 
chitis occurring with 
pneumonia or phthisis. 



Same diseases as the 
sonorous rales, and indi- 
cating that the smaller 
tubes are affected. 



32 AUSCULTATION AND PERCUSSION. 

TABLE NO. 5, Continued. 



VARIETIES. 



b. Moist or bub- 
bling. 



(1.) Coarse Bub- 
bling Bales. 

(Coarse mucous 
rales.) 



(2.) Fine Bub- 
bling Bales. 

(Fine mucous rales.) 



(3.) Subcrepi- 
tant Bales. 



CHARACTER OF THE SOUND. 



A coarse bubbling sound, 
conveying the impression of 
the bursting of bubbles of 
somewhat large size. The 
"death-rattles" are an ex- 
aggerated type of them. If 
any solidification of the lung 
exists around the tubes in 
which the sound is produced, 
the pitch is raised in propor- 
tion to the amount. 



The same quality of sound, 
but the bubbles are smaller. 
The coarse and fine bub- 
bling rales may be imitated 
by blowing into a tumbler 
of water through different 
sized tubes. 



The same quality, but the 
bubbles are very small in- 
deed. Still, they are some- 
what unequal in size, as in 
the other moist rales. 
Slowly evolved. 



RELATION TO inspiration 

AND EXPIRATION. 



With either or both. 



With either or both. 



With either or both. 
When with inspiration, 
near the beginning. 



AUSCULTATION AND PERCUSSION. 
RALES, Continued. 



HOW PRODUCED. 



By the bubbling of air 
through liquid (mucus, 
pus, softened tubercle, 
Wood, or serum), in the 
larger bronchial tubes. 
Bubbling rales, both 
coarse and fine, are very 
often called mucous rales. 
This term is not so ap- 
propriate, as the liquid 
by means of which they 
are produced is not al- 
ways mucus. Unless 
specified, when "bubbling 
rales " are mentioned, 
bronchial and not tra- 
cheal are understood. 



Produced in the same 
manner in the smaller 
bronchial tubes. 



Produced in the same 
manner in the very mi- 
nute bronchial ramifica- 
tions. 



USUAL SEAT. 



Constantly liable to 
change position, espe- 
cially after expectora- 
tion or coughing, and 
not occurring with every 
respiration. 

They are either — 

1. More or less dif- 
fused over the whole 
chest, especially the in- 
fra-scapular regions, or 

2. Confined to one side 
of the chest, or limited 
to a circumscribed space. 
(In phthisis the circum- 
scribed space is generally 
the summit of the chest.) 



Same as coarse bub- 
bling rales, with which 
they are frequently min- 
gled. 



Same as coarse bub- 
bling rales, excepting 
that they are very much 
less liable to change po- 
sition. 



DISEASES INDICATED. 



1. Bronchitis. 

2. Circumscribed bron- 
chitis, occurring with 
phthisis or pneumonia. 

Softened tubercle, etc., 
in tubes in phthisis, blood 
in haemoptysis or pulmo- 
nary apoplexy, serum in 
oedema, pus in pulmo- 
nary or hepatic abscess. 



Same as coarse bub- 
bling rales, but smaller 
tubes affected. 



1 . Capillary bronchitis. 
Pulmonary oedema. 

2. Lobar pneumonia 
during resolution. 

Incipient phthisis. 



34 AUSCULTATION AND PERCUSSION. 

TABLE NO. 5, Continued. 



VARIETIES. 


character of the sound. 


relation to inspiration 
and expiration. 




Fine, dry, crepitating or 


With inspiration exclusively, 




crackling sounds, compared to 


and near the end of it, es- 




those produced by tine salt 


pecially in forced inspira- 


III. Vesicular 


on a fire, or by rubbing a 


tion. 


Kales. 


lock of hair between the 
thumb and finger close to 
the ear. They resemble the 




Crepitant 


subcrepitant, from which 




Bales. 


they must be distinguished. 
The crepitations are equal in 
size, dry, not bubbling, con- 
stant, not variable, rapidly 
evolved, not suspended by 
coughing and expectoration, 
and occur only with inspira- 
tion. 






A hollow, gurgling sound, 


With either or both. 




often very intense, some- 


Oftener with inspiration 




times metallic or amphoric, 


than expiration. 


IV. Cavernous 


usually of low pitch, convey- 




Bales. 


ing the impression of very 
large bubbles bursting in a 
large space, the loudness of 




Gurgling 


the gurgling being propor- 




Bales. 


tionate to the size of the cav- 
ity. When this is small, 
hardly distinguishable from 
coarse bubbling bronchial 
rales. 





AUSCULTATION AND PERCUSSION. 
RALES, Continued. 



35 



HOW PEODUCED. 



Produced, according to 
the most rational theory 
(Dr. Carr's), by the abrupt 
separation, during inspi- 
ration, of the walls of the 
air-vesicles, which had, 
after the preceding ex- 
piration, become adherent 
by means of the viscid 
exudation incident to the 
early stage of inflamma- 
tion. 

This mode of its production 
can be illustrated by moisten- 
ing the thumb and finger with 
a little paste or solution of 
gum arabic, and alternately 
pressing them together and 
separating them near the ear. 



Produced by the burst- 
ing of large bubbles and 
the agitation of a mass of 
liquid in a cavity of con- 
siderable size. When the 
cavity is empty, cavern- 
ous respiration takes the 
place of the cavernous 
rales. The two signs 
may thus confirm each 
other. Not produced if 
the cavity is full. The 
communication with the 
bronchial tubes must be 
unobstructed and below 
the level of the liquid. 
Therefore gurgling is not 
heard in every case of a 
cavity. 



USUAL SEAT. 



Most commonly over 
the lower part of the 
chest behind, on one side, 
oftener the right. 

Often associated with 
the subcrepitant rales in 
the resolution of pneu- 



A circumscribed space, 
in forty-nine out of fifty 
cases at the summit of 
the chest. 



DISEASES INDICATED. 



Almost pathognomonic 
of pneumonia. 

If heard only over a 
circumscribed space at 
the summit of the chest, 
phthisis is generally indi- 
cated. Even in such 
cases the crepitant rale is 
indicative of a circum- 
scribed pneumonic proc- 



Phthisis. 

Cavity from 
cumscribed 
cer, etc. 



36 



AUSCULTATION AND PERCUSSION. 



TABLE NO. 



VARIETIES. 


CHARACTER OF THE SOUND. 


RELATION TO INSPI- 
RATION AND EX- 
PIRATION. 


Friction 

Sounds. 


Grazing, rubbing, creaking like new 
leather, grating, crumpling, rasping, 
the harshness varying according to 
the roughness of the surface of the 
pleura. 

The grazing and rubbing sounds, 
which are the most common, may be 
imitated by placing over the ear the 
palm of one hand and moving over 
its dorsal surface slowly the pulpy por- 
tion of a finger of the other hand. 

Intensity very variable, sometimes 
heard even by the patient. The 
sound is dry and appears to be near 
the ear, not continuous generally, but 
jerking, rhythmical with respiration. 
Transient or lasting. Occasionally 
attended with fremitus. 


With both or with 
inspiration alone. 

Very rarely with 
expiration alone. 


Metallic Tink- 
ling. 


A high-pitched, abrupt, short, sil- 
very tone, like the tinkling of a small 
bell, dropping small shot into a brass 
basin, etc., consisting of a single 
sound, or more commonly of two, 
three, or more in quick succession. 
Accompanies respiration, speaking, 
and coughing, especially the two lat- 
ter. Irregular in its appearance. 
Only liable to be confounded with a 
somewhat similar sound in the stom- 
ach. 


With both or 
either ; especially 
at the end of inspi- 
ration. 



AUSCULTATION AND PERCUSSION. 



37 



MORBID PLEURAL SOUNDS. 



HOW PRODUCED. 



By the rubbing together of two 
pleural surfaces (pulmonary with cos- 
tal, and often diaphragmatic with cos- 
tal) which have been roughened by 
lymph or other deposit. 



There must be a large cavity, contain- 
ing liquid and air or gas, and almost 
invariably there is communication with 
a bronchial tube. 

There are several different theories 
as to the production of this sound, and 
probably each one of the following 
(which have all been experimentally 
verified) may account for it either alone 
or in connection with the others. 

1. Drops of fluid fall from the upper 
part of the space upon the surface of 
the liquid below, when the patient, 
previously lying down, sits or stands 
up. (Laennec. ) 

2. Air, working through a fistulous 
orifice opening below the level of the 
liquid, rises to the surface, forming bub- 
bles which break and produce the 
sound. (Spittel.) 

3T Simple agitation of the liquid may 
give rise to the sound, as in succussion, 
coughing, etc. 

4. Bubbles of mucus bursting at the 
opening of a fistulous orifice situated 
above the level of the liquid. 



USUAL SEAT. 



In comm on 
pleurisy usually 
confined to a 
small space at the 
middle or lower 
part of the chest 
laterally or pos- 
teriorly ; but may 
be more or less 
diffused, and occa- 
sionally is heard 
over the entire 
chest. 

In phthisis at 
the summit of the 
chest. 



Generally at the 
middle third of 
the chest, in front, 
behind, or at the 
side. 

Sometimes dif- 
fused over the 
entire chest on 
one side. 

Sometimes a 
circum scribed 
space at the sum- 
mit 



DISEASES INDI- 
CATED. 



Pleurisy. 

Also in phthisis 
and pneumonia 
where there is ac- 
companying sec- 
ondary pleurisy. 



Almost pathog- 
nomonic of pneu- 
mo-hydrothorax. 

Very rarely in 
phthisical cavities. 



38 



AUSCULTATION AND PERCUSSION 



TABLE NO. 6, Continued. 



Splashing. 



(Hippooratic succus- 
sion sound.) 



CHARACTER OF THE SOUND. 



Such a noise as is produced by- 
shaking a bottle partly filled with 
liquid. 

Only liable to be confounded with a 
somewhat similar sound in the stom- 
ach. 

Often it has a high-pitched am- 
phoric tone, and may be mingled with 
metallic tinkling. Sometimes loud 
enough to be heard at a distance. 



RELATION TO INSPI- 
RATION AND EX- 
PIRATION. 



AUSCULTATION AND PERCUSSION. 
MORBID PLEURAL SOUNDS, Continued. 



39 



HOW PRODUCED. 



Produced by jerking the body of the 
patient with an abrupt forcible move- 
ment, the ear being in contact with or 
in close proximity to the chest. 

Sometimes produced unintentionally 
by the patient himself, by quick mo- 
tions, such as horseback exercise, 
jumping, etc. 

The liquid must not be too abun- 
dant nor too thick, and there must 
also be air in the cavity. 



USUAL SEAT. 



Generally over 
the whole of the 
affected side, un- 
less there are ad- 
hesions. 



Very rarely at the 
summit of the chest. 



DISEASES IN- 
DICATED. 



Pathognomonic 
of pneumo-hydro- 
thorax. 

Very rarely in tu- 
bercular and other 
cavities in the lung. 



40 AUSCULTATION AND PERCUSSION. 

TABLE NO. 7. 



VARIETIES. 


CHARACTER OF THE SOUND. 


Tracheal Voice. 

(Tracheophony, laryn- 
geal voice, laryngoph- 
ony.) 


A strong resonance, with a powerful sensation of con- 
cussion or shock, and also with a strong sense of vibration 
or thrill called fremitus, which can be appreciated by the 
ear as well as by palpation. The voice is concentrated and 
near the ear, seeming to pass right through the stethoscope. 
Sometimes the articulated words are transmitted so as to 
be heard as distinctly as when coming direct from the 
lips. When this occurs over the chest as a result of dis- 
ease, it is called perfect pectoriloquy . Oftener, however, 
the transmission of speech from the trachea furnishes a 
type of imperfect pectoriloquy. All these phenomena 
may differ in intensity. The variations in the first three, 
however, — resonance, shock, and fremitus, — do not al- 
ways correspond with the variations in the distinctness 
with which speech is transmitted. 


Tracheal 
Whisper. 

(Whispering 
tracheophony.) 


There is little or no shock or fremitus. Whispered 
words are transmitted more or less perfectly, more so 
generally than loud words ; this feature corresponding to 
the morbid sign called whispering pectoriloquy. 


Normal Thoracic 

Vocal 

Resonance. 


The resonance is much weaker than in tracheophony, 
and is quite variable in intensity. Often over portions of 
the chest none is appreciable, and in some persons it is 
absent over the entire chest. The sound is diffused and 
seems farther removed from the ear, rarely accompanied 
with shock, and not always with fremitus. The sound 
often amounts to little more than a humming or buzzing. 
No pectoriloquy. 


Normal 
Bronchial 
Whisper. 


The characters of the sounds produced by the whis- 
pered voice are identical with those produced by the act of 
expiration, in all respects except that the sounds are more 
intense, generally, than those even of a forced expira- 
tion. The intensity is variable, as in the preceding. 
There is the same difference between this and the tracheal 
whisper with regard to diffusion, concentration, and near- 
ness to the ear that there is between the normal thoracic 
vocal resonance and the tracheal voice. 



AUSCULTATION AND PERCUSSION. 
THE VOICE IN HEALTH. 



41 



HOW PRODUCED. 


USUAL SEAT. 


The resonance by the reverberation 
of the voice in the sound-reflecting 
tube, the shock by the sudden arrest 
of the column of expired air by the 
act of speaking, the fremitus by the 
vibrations of the tracheal tube in con- 
nection with those of the vocal chords, 
and the distinct transmission of speech 
by the concentrating and sound-reflect- 
ing properties of the hollow tube. 


Trachea and larynx. 

Apply the stethoscope over the broad sur- 
face of the thyroid cartilage or just above 
the sternal notch. To bring out the vocal 
phenomena to the best advantage, both here 
and over the chest in health and in disease, 
the patient should be instructed to count 
slowly one, two, three, one, two, three, etc., 
at first with the loud voice and afterwards in 
a whisper. 


The sound corresponds to the sound 
of expiration in tracheal or laryngeal 
respiration, and is in fact identical 
with it. 


Trachea and larynx. 


The vibrations are weakened and 
diffused by passing through the sub- 
divisions of the bronchi and the 
spongy tissue of the lung before reach- 
ing the surface of the chest. 


There are considerable variations 
in this sound in the different regions 
of the chest, it being more intense in 
the infra-clavicular and inter-scapular 
regions than in the axillary and infra- 
axillary ; and in the latter more than 
in the mammary and infra-mammary. 
There is the least resonance in the 
scapular region. 

There is also often a slight difference in 
the two sides comparatively. When there is 
any difference, the right side is the more 
resonant. This last remark applies also to 
fremitus. The amount of the fremitus, how- 
ever, is not necessarily proportionate to that 
of the resonance. 


The conduction of sound by the 
whispered voice is chiefly by the air 
contained in the bronchial tubes. 


About the same variations are ob- 
served as in the preceding. 



42 AUSCULTATION AND PERCUSSION. 

TABLE NO. 8. 



VARIETIES. 


character of the sound. 


Diminished and Sup- 
pressed Vocal 
Resonance and Fre- 
mitus. 


Simply less in intensity than normal, or absent 
altogether. There being no standard of intensity, 
comparison must be made between the two sides, 
allowing, of course, for the slight possible differ- 
ence in health. (Table No. 7.) 

The fremitus generally, but not always, lessened 
in the same proportion as the resonance. 


Increased Vocal 

Resonance and 

Fremitus. 


Merely an increase in intensity, without change 
in other respects. Generally associated with the 
broncho-vesicular respiration. 


Increased Bronchial 
Whisper. 


Same as the expiratory sound in broncho-vesic- 
ular respiration, namely, increase of intensity and 
length, more or less tubular in quality, and higher 
in pitch than the whisper in health, these altera- 
tions being proportionate to the degree of solid- 
ification. 


Bronchophony. 


Vocal sound concentrated and near the ear. 
Pitch higher than normal. Intensity and fremi- 
tus variable ; may be greater or less than in 
health. 


"Whispering Bron- 
chophony. 


Same as the expiratory sound in the bronchial 
respiration, namely, intensified, long, high pitched, 
and tubular. 



AUSCULTATION AND PERCUSSION. 
THE VOICE IN DISEASE. 



43 



HOW PRODUCED. 



By the removal of the 
lungs from the thoracic 
walls, or by anything that 
prevents the circulation of 
the column of air in the 
tubes which propagate the 
sound. 



By slight consolidation of 
the lung tissue around the 
air tubes, whereby the 
sound-reflecting power of 
the tubes is increased, and 
the pulmonary parenchyma 
is rendered more homoge- 
neous and a better sound- 
conductor. 



Same as the preceding. 



Same as the preceding, 
except that the solidifica- 
tion is greater, and some- 
times complete. Less solid- 
ification is required than 
for the production of bron- 
chial respiration. There- 
fore bronchophony may be 
associated with a broncho- 
vesicular respiration as 
well as with bronchial. 



Same as the preceding. 



USUAL SEAT. 



When the pleural 
cavity is partially filled 
with fluid, the* vocal 
resonance and fremitus 
are diminished or sup- 
pressed below the level 
of the liquid, but in- 
creased generally just 
above the level, owing 
to the condensation. 



Not confined to any 
part of the chest, but 
usually most marked 
and of the greatest sig- 
nificance towards the 
apices of the lungs in 
phthisis. 



Same as the preceding. 



In pneumonia gen- 
erally the middle and 
lower thirds behind. 

Of great importance 
as suggestive of phthisis 
when existing at the 
apex of the lung. 

In pleuritic effusion, 
over condensed lung at 
summit of chest. 



Same as the preced- 
ing. 



DISEASES INDICATED. 



Pleuritic effusion, em- 
pyema, hydrothorax, 
pneumo - hydrothorax, 
obstruction of bron- 
chial tubes by mucus or 
by the pressure of aneu- 
rismal or other tumors. 

Exceptional in solidifica- 
tion, but sometimes observed 
in complete solidification of 
pneumonia, abscess full of 
pus, cavity filled with liquid, 
pulmonary oedema. 



Phthisis. 

Pneumonia. 

Compressed lung in 
moderate pleuritic ef- 
fusion and collapse of 
pulmonary lobules. 

Carcinoma, hsemorrhagic 
infarctus. Sometimes over 
cavities. 



Same as the preceding. 



Pneumonia. 

Phthisis. 

Lung condensed by effu- 
sion in pleurisy or pneumo- 
hydrothorax, or by pressure 
of a tumor, collapse of 
pulmonary lobules, cancer, 
or bronchial dilatation, the 
tubes being surrounded by 
condensed and indurated 
lung. 



Same as the preced- 
ing. 



44 AUSCULTATION AND PERCUSSION 

TABLE NO. 8, Continued. 



VARIETIES. 


character of the sound. 


Cavernous Whisper. 


Same as the expiratory sound in the cavernous 
respiration, namely : low pitch and blowing (non- 
tubular) quality, with variable intensity. 


Amphoric Voice and 
Whisper. 


A ringing sound of a metallic quality, not dis- 
tinctly articulated, not transmitted forcibly 
through the stethoscope, but resembling the 
sound produced by speaking into an empty jar. 
The amphoric quality may accompany the loud 
voice or whisper, more especially the latter, the 
resonance and fremitus of the loud voice obscuring 
somewhat the musical intonation. 


Pectoriloquy and 
Whispering Pecto- 
riloquy. 


Articulated words are transmitted directly through 
the stethoscope into the ear. This is more fre- 
quent with the whispered than with the loud 
voice. Care must be taken not to confuse the 
words coming directly from the patient's mouth 
with the transmission of them through the chest. 
Unless a double stethoscope is used, one ear must 
be closed. This is a rare sign, but the type of it 
can be studied in health in connection with 
tracheal voice. 


JEgophony. 


A tremulous, bleating or quavering sound, like 
the cry of a goat, from which the term is derived, 
and often compared to the "Punch and Judy" 
voice. Synchronous with, but of a higher pitch 
than, the" voice of the patient, or else follow- 
ing it like a feebly whispered echo, and rarely 
traversing the stethoscope. 


Metallic Tinkling. 


Has the same characters when heard in connec- 
tion with the loud or whispered voice as with res- 
piration (which see), but is more intense. 



AUSCULTATION AND PERCUSSION. 
THE VOICE IN DISEASE, Continued. 



45 



HOW PRODUCED. 


USUAL SEAT. 


DISEASES INDICATED. 


Produced by the air 
passing- out of an empty, 
superficial cavity with flac- 
cid walls. 


A circumscribed space, 
generally at summit of 
chest, — 

Or in other parts. 


Phthisis. 

Purulent, gangrenous, or 
cancerous excavation. 


By the reverberation of 
the voice, causing an echo, 
in a large cavity with rigid 
walls, and subject to the 
same conditions as in the 
production of amphoric 
respiration (which see). 


Same as amphoric 
respiration. 


Same as amphoric 
respiration. 


" Sometimes by the con- 
densation of lung tissue 
around a large bronchus, 
whereby the transmission 
of the sound to the ear is 
facilitated. More gener- 
ally by the formation of 
cavities possessing smooth, 
sound-reflecting walls." 


" Not confined to any 
portion of the lungs, 
but occurring most 
commonly at the apices 
and in the upper lobes." 


Chiefly Phthisis. 

Sometimes pneu m o n i a, 
pouclilike dilatation of bron- 
chi, circumscribed gangrene, 


By the vibrations conse- 
quent on the existence of a 
thin stratum of liquid in 
the pleural cavity. 

Not apt to occur when 
the chest is more than half 
full of liquid. The lung 
must be more or less con- 
densed at the level of the 
liquid. This accounts for 
the elevation of pitch. 
When there becomes too 
much liquid, the segophony 
stops. Therefore in acute 
pleurisy it rarely continues 
longer than two or three 
days, sometimes only for a 
few hours. 


Not confined to any 
portion of the chest, 
but most common at or 
near the inferior angle 
of the scapula; from 
here often extending 
to the inter-scapular 
space, and, in a zone 
from one to three fin- 
gers broad, following 
the line of the ribs to- 
wards the nipple (the 
patient sitting). This 
line indicates not the 
level of the liquid, but 
the points where it has 
the requisite degree of 
thinness to produce 
ajgophony. 


Pleuritic effusion. 

Pleuro-pneumonia. 

Hydrothorax. 

Empyema. 


As in Table No. 6. 


As in Table No. 6. 


Mostly Pneumo-hy- 
drothorax. 



46 



AUSCULTATION AND PERCUSSION 
TABLE NO. 9. 



VARIETIES. 


CHARACTER OF THE SOUND. 


HOW PRODUCED. 


Nokmal Vesic- 
ular 
Resonance. 

(Pulmonary.) 


A full, clear, prolonged 
sound, of low pitch, its qual- 
ity sui generis, only to be ap- 
preciated by actually bearing 
it, and its intensity varying 
with the force of the blow, 
the elasticity of the chest 
walls, the thickness of the 
layer of muscles and fat cov- 
ering them, and the degree 
of inflation of the lungs. 


By the vibration of the 
air in the uniform, elastic, 
spongy tissue of the lung 
when percussed. 


Flatness. 

(Absence of reso- 
nance.) 


The sound is completely 
deadened, and resembles that 
produced by percussing the 
thigh or shoulder. The 
finger used as a pleximeter 
experiences a greater sense 
of resistance than normal, 
especially in early life, before 
the costal cartilages have 
ceased to be elastic. 


The absence of resonance 
is occasioned by serum or 
pus in the pleural sac, serum 
in the air-vesicles, complete 
solidification of lung tissue, 
tumors, etc. 


Dullness. 

(Diminished reso- 
nance.) 


Intermediate between the 
two preceding, the vesicular 
resonance being not lost but 
only partially deadened. The 
degree of dullness varies in- 
definitely. The pitch is 
higher than normal. The 
sense of resistance is in- 
creased in proportion to the 
degree of dullness. 


By the same causes as the 
preceding, though existing 
to a lesser extent. The rela- 
tive proportion of solids or 
liquids to air in the lungs is 
morbidly increased. 



AUSCULTATION AND PERCUSSION. 
PERCUSSION SIGNS. 



47 



WHERE OBSERVED IN HEALTH. 



Most strongly marked in the infra- 
clavicular regions. In the scapular 
and interscapular regions, on account 
of the layers of bone and muscles, the 
resonance is diminished, as it is also 
where the lung overlaps the heart and 
liver. In different regions the reso- 
nance varies so much that what would 
be normal for one would be decidedly 
abnormal for another. Each must be 
carefully studied by itself. The area of 
healthy resonance is of course greater 
with a full inflation of the lungs than 
in tranquil breathing, and less with a 
forced expiration. 

In some persons the resonance is slightly 
diminished on the right side in the infra- 
clavicular region in health, but never on the 
left side. 



Over the liver below the line of he- 
patic flatness. 

The lower border of the right lung marks 
the line of hepatic flatness, and the upper 
border of the underlying liver the line of 
hepatic dullness. 



Over the heart and spleen ; in the 
places where the lungs overlap the 
liver or heart ; over the mammary 
gland in females ; over thick layers of 
muscles on the ribs, especially behind ; 
and all over the chest in very fat per- 



In some persons there is in health a slight 
degree of dullness at the summit of the chest 
on the right side. 



DISEASES INDICATED. 



Pneumonia. 
Pleuritic effusion. 
Empyema. 
Hydrothorax. 

Phthisis, pulmonary oedema, condensation 
of lung from compression or from pulmonary 
collapse, cancer, aneurism, etc. 



The same diseases as the above, 
where the same physical conditions 
exist to a less extent. In many of 
them dullness is more common than 
flatness. The deposit of phthisis is 
very rarely sufficient to give rise to 
more than dullness, and miliary tuber- 
cles, unless in great quantities, may 
not even give rise to dullness. Con- 
gestion of the lung may give rise to 
dullness, but never to flatness. 

Rarely we find dullness in emphysema, 
owing probably to increased tension of lungs 
and walls of chest. There may be slight dull- 
ness from exudation of lymph on pleura. 



48 AUSCULTATION AND PERCUSSION. 

TABLE NO. 9, Continued. 



VARIETIES. 



Tympanitic 
Resonance. 



CHARACTER OF THE SOUND. 



A drum-like sound, as its 
name signifies ; the term 
often used to denote any res- 
onance which is not vesic- 
ular. It is of variable in- 
tensity, either greater or less 
than the vesicular, of higher 
pitch, and accompanied with 
a sense of less resistance to 
the finger. 



HOW PRODUCED. 



It requires for its produc- 
tion a large space filled with 
air, and bounded by moder- 
ately tense, clastic walls, capa- 
ble of reflecting sonorous vi- 
brations. If, however, the 
tension is extreme, the con- 
tained air does not vibrate, 
the tympanitic quality is 
lessened or destroyed, and 
the sound may become quite 
dull. When a' common drum 
is made extremely tight and 
there is no escape for the air, 
the same dull effect is pro- 
duced on being struck. 

Tympanitic resonance oc- 
curs under the following con- 
ditions : — 

1. From air or gas in the 
pleural cavity. (Here the 
resonance is more intense 
than the normal vesicular.) 

2. From air in pulmonary 
cavities. 

3. Singularly enough, and 
contrary to what might be 
expected, tympanitic reso- 
nance is often heard over 
partially solidified lung (giv- 
ing place to dullness when 
the solidification becomes 
complete). 

Where the upper lobe is thus 
resonant, as in phthisis before 
cavities have formed, and in pneu- 
monia, it is generally explained 
by saying that the resonance must 
come from the air in the lower 
part of the trachea and the pri- 
mary bronchi, being better con- 
ducted by solidified than by 
healthy lung ; and where the 
lower lobe is solidified, that the 
tympanitic resonance, if present, 
is conducted iria similar way from 
the stomach or colon. Fuller, 
however, thinks it comes from the 
presence of air pent up in lung 
tissue in the immediate vicinity of 
consolidated tissue. Skoda and 
others explain it by diminution of 
tension. 



AUSCULTATION AND PERCUSSION. 
PERCUSSION SIGNS, Continued. 



49 



WHERE OBSERVED IN HEALTH. 



Heard over the stomach and bowels. 



DISEASES INDICATED. 



Pneumothorax. 

Pneumo-hydrothorax. 

Phthisis. 



Cavities after abscess, etc. 
Dilatation of bronchi. 
Pneumonia. 



50 AUSCULTATION AND PERCUSSION. 

TABLE NO. 9, Continued. 



VARIETIES. 


character of the sound. 


how produced. 


Exaggerated 
Resonance. 

(Vesiculotym- 
panitic.) 


Intermediate between the 
normal vesicular and the 
tympanitic resonance, and 
partaking of the characters 
of each. The pitch high in 
proportion as the tympanitic 
quality predominates. In- 
tensity greater than normal. 


1 . By abnormal dilatation 
of the air cells. 

2. If the effusion in pleu- 
risy rises much above the 
middle of the chest, the pres- 
sure condenses the lung above 
the liquid, and dullness en- 
sues. With a less amount 
of liquid, however, the reso- 
nance is generally exaggera- 
ted. Also, where pneumonia 
solidifies one lobe, the reso- 
nance over the other is gen- 
erally exaggerated. Prob- 
ably both cases are explained 
by assuming a condition ap- 
proximating to emphysema 
in the lobe above the liquid 
in pleurisy, and in the 
healthy lobe in pneumonia, 
they expanding proportion- 
ally to the expansion caused 
by the diseased condition in 
the affected part. 


Amphoric 
Resonance. 


A kind of musical intona- 
tion, like the sound obtained 
by percussing an empty jar 
(amphora). It may be imi- 
tated by closing the mouth, 
inflating the cheeks, but not 
too tensely, and then filliping 
them with the finger. 


The cavity must contain 
air, must have somewhat 
rigid walls, must be super- 
ficial or else covered by so- 
lidified lung, and there must 
be free communication with 
the bronchial tubes. The 
sound can be heard better 
if the ear or stethoscope is 
brought close to the patient's 
open mouth. Use slow and 
heavy percussion. 


Cracked-Metal 
Resonance. 

(Bruit du pot fele\) 


Like the sound produced 
by striking a cracked earth- 
enware or metal jar or other 
vessel. Can be imitated by 
the school-boy trick of fold- 
ing the hands so as to form 
a hollow, and striking the 
back of one of them on the 
knee. A loud, short, hollow, 
metallic sound, accompanied 
with hissing. 


Produced exactly as in the 
school-boy trick referred to, 
by the sudden expulsion of 
air, and its forcible contact 
with the sides of the passage 
through which it is driven. 
The same conditions are nec- 
essary to its production as in 
amphoric resonance. 



AUSCULTATION AND PERCUSSION. 
PERCUSSION SIGNS, Continued. 



51 



WHERE OBSERVED IN HEALTH. 


DISEASES INDICATED. 




Emphysema (vesicular or interlob- 
ular or secondary to phthisical de- 
posit, etc.). 

Pleurisy with effusion. 

Pneumonia. 


Occasionally produced in children 
over a primary bronchus, owing to the 
yielding of the costal cartilages. 


Mostly phthisical cavities, some- 
times pneumo-hydrothorax. 

Occasionally at the summit of the chest in 
pleurisy with effusion. 


As in the preceding. 

It may be produced unintentionally 
by the imperfect application of the 
finger or pleximeter to the chest walls, 
and the expulsion of air from beneath 
it. 


Mostly phthisical cavities. 

Occasionally in solidification of the upper 
lobe from inflammation or condensation, 
where the air is suddenly and forcibly ex- 
pelled through the bronchus, especially if 
percussed near the sternum. 



PART II. 

THE PHYSICAL DIAGNOSIS OF DISEASES 
OF THE LUNGS AND HEART. 



54 



THE PHYSICAL DIAGNOSIS 
TABLE NO. 10. 



DISEASE. 


inspection and 
mensuration. 


percussion. 


RESPIRATION. 


Acute 
Pleurisy. 

First Stage. 

(Exudation of 
lymph.) 


Diminution in 
respiratory move- 
ments on account 
of pain. Body bent 
towards affected 
side for the same 
reason. 


Sometimes slight 
dullness. 


Feeble. 
Jerking. 


Second Stage. 

(Effusion of 
serum.) 


Little or no mo- 
tion of the chest 
walls on the affect- 
ed side, but in- 
creased motion on 
the healthy side. 

Enlargement of 
side in all direc- 
tions by measure- 
ment, and oblitera- 
tion of intercostal 
spaces, especially 
at lower part of 
chest. 


A sense of re- 
sistance, and flat- 
ness or dullness at 
the base of the 
chest, terminating 
abruptly above in 
a curved line which 
is not altered by 
respiration, but 
which may be made 
to shift by chang- 
ing the patient's 
posture, unless 
there are adhesions 
of the pleural sur- 
faces, or the chest 
is full of liquid. 

Generally exag- 
gerated resonance 
above the level of 
the liquid, and 
rarely the amphoric 
or the cracked- 
metal resonance at 
the summit. 


Feeble, broncho- 
vesicular or bron- 
chial respiration 
over the compressed 
lung, with occa- 
sionally a feeble, 
distant, bronchial 
respiration all over 
the chest. 

Eespiration gen- 
erally suppressed 
below the level of 
the liquid, but in- 
creased on unaf- 
fected side during 
all three stages, 
especially in this 
stage. 


Third Stage. 

(Absorption and 
resolution.) 


Mobility of chest 
walls partially re- 
turning, intercostal 
spaces becoming 
normal, and en- 
largement disap- 
pearing. 

After recovery 
there occurs, in 
some cases 
(though seldom in 
comparison with 
chronic pleurisy), 
contraction of the 
whole side. 


The line of flat- 
ness is gradually 
lowered, but dull- 
ness often remains 
for an indefinite 
time at the base of 
the chest, where 
the compression of 
the lung and the 
accumulation of 
solid plastic mate- 
rial is often very 
great. 


Eespiration grad- 
ually returns to its 
normal condition 
from the summit 
downwards, though 
feeble often for 
weeks and months. 

Absence of respi- 
ration at the base 
frequently remains 
for a long time. 



OF DISEASES OF THE LUNGS. 
TABLE NO. 10. 



55 



rales. 


VOCAL 
RESONANCE. 


PALPATION. 


EEMAEKS. 


Rubbing friction 
sounds often 
heard, which are 
almost pathogno- 
monic when at 
the middle or infe- 
rior part of chest, 
or all over the side. 




Deep-seated ten- 
derness. 


When not spe- 
cified, the signs 
mentioned in this 
table are ob- 
served over the 
affected portion 
of the lung only. 


A friction 

sound is rarely 
heard even in this 
stage, where the 
lung is attached 
by bands of false 
membrane to the 
thoracic walls, 
and also over the 
compressed lung 
higher up. 


Lessened or 
suppressed below 
the level of the 
liquid, but in- 
creased above. 
Sometimes bron- 
chophony above 
the level, or pec- 
toriloquy (espe- 
cially in pleuro- 
pneumonia, or 
pleurisy with 
phthisis), heard 
best over the 
scapular and in- 
terscapular re- 
gions on account 
of the usual sit- 
uation of the 
compressed lung. 
Sometimes 
asgophony near 
the level of the 
liquid. 


Fluctuation some- 
times apparent. Vo- 
cal fremitus lessened 
or suppressed below 
the level of the liquid, 
but increased above. 

If the heart is dis- 
placed, it may be 
heard and often felt 
pulsating even to the 
right of the sternum, 
or farther to the left 
than normal in the 
direction of the ax- 
illa ; the displace- 
ment being to the 
right if the effusion 
is on the left side, and 
to the left if the effu- 
sion is on the right 
side. 


Generally the 
pleural cavity is 
not more than 
half or two thirds 
full in acute 
pleurisy. 


A rasping, grat- 
ing, creaking, 
rough, frictio n 
murmur is now 
very often ob- 
served, especially 
with a deep in- 
spiration, some- 
times loud enough 
to be heard at a 
distance, and va- 
rying in duration 
from a very short 
time to several 
months, ceasing 
with adhesion. 


Gradually ap- 
proaches to the 
normal. Some- 
times asgophony. 


Sometimes a fric- 
tion fremitus. The 
heart, if previously 
displaced, gradually 
returns to the pra> 
cordia, unless held 
by morbid adhesions ; 
and curiously enough, 
the suction force 
caused by absorption 
may now even draw 
it too far in the oth- 
er direction, — if the 
effusion has been 
right-sided, towards 
the right; if left- 
sided, further to the 
left than normal. 


^ 



56 



THE PHYSICAL DIAGNOSIS 
TABLE NO. 10, Continued. 



DISEASE. 


INSPECTION AND 
MENSURATION. 


PERCUSSION. 


RESPIRATION. 


Chronic 
Pleurisy. 

(If the chest is 
full of fluid.) 


Perfect or almost 
perfect immobility 
of side of chest 
(with increase of 
motion on healthy 
side). Generally di- 
latation of side, 
and as a rule, even 
if this be not so, 
the intercostal de- 
pressions are ef- 
faced or lessened. 
This is particularly 
noticeable at the 
end of inspiration. 
The maximum en- 
largement of the 
side is about two 
inches. 

• Permanent con- 
traction after re- 
covery. 


Flatness every- 
where on affected 
side, even extend- 
ing over the ster- 
num some distance 
on the other side. 


Wanting ; except 
at the summit over 
or near the com- 
pressed lung, where 
it is bronchial. Ex- 
ceptionally, how- 
ever, the bronchial 
respiration extends 
over the whole side 
or the greater part 
of it. 

Kespiratory mur- 
mur exaggerated on 
healthy side. 


Empyema. 


The amount of 
pus is generally 
even greater than 
that of the serum 
in chronic pleurisy, 
causing still greater 
dilatation of the 
chest. The obliter- 
ation of intercostal 
depressions is oft- 
ener noticed than 
in pleurisy. 


Same as chronic 
pleurisy. 


Same as chronic 
pleurisy. 



OF DISEASES OF THE LUNGS. 
TAELE NO. 10, Continued. 



57 



kIles. 


VOCAL 

RESONANCE. 


PALPATION. ■ 


REMARKS. 


As in acute 
pleurisy. 


Lessened o r 
suppressed ex- 
cept at the sum- 
mit behind, 
where there may 
be loud and whis- 
pering bron- 
chophony and in- 
creased vocal res- 
onance. JEgoph- 
ony is rare. 


Fluctuation some- 
times apparent. Vo- 
cal fremitus lessened 
or suppressed. 

Heart displaced 
even more than is 
usual in acute pleu- 
risy. Mediastinum 
displaced laterally. 
Liver and stomach 
often displaced down- 
wards, sometimes as- 
cending even higher 
than before with the 
contraction accom- 
panying recovery. 


If the chest is 
only partially 
filled, the signs 
are the same as 
in acute pleurisy. 
It is far more 
common to have 
the chest full in 
chronic than in 
acute pleurisy. 


Same as chron- 
ic pleurisy. 


Same as chron- 
ic pleurisy. 


Even more dis- 
placement of the 
heart generally than 
in chronic pleurisy, 
it pulsating some- 
times even beyond 
the right nipple. If 
the left side is affect- 
ed, the effusion often 
receives a tangible 
and visible impulse 
from the heart's beat ; 
hence the term " pul- 
sating empyema." 

If a spontaneous 
perforation takes 
place through the 
chest walls, and the 
skin remains un- 
broken, the tumor 
thus formed, besides 
fluctuating, often has 
a strong pulsation, 
synchronous with the 
systole, simulating 
aneurism. The tu- 
mor may also in- 
crease and decrease 
with respiration. 





58 



THE PHYSICAL DIAGNOSIS 
TABLE NO. 10, Continued. 



DISEASE. 


INSPECTION AND 

MENSURATION. 


PERCUSSION. 


RESPIRATION. 


Hydro- 
thorax. 


Although there 
may be more liquid 
on one side than on 
the other, yet there 
is almost never one- 
sided dilatation of 
the chest and dis- 
placement of the 
heart and medias- 
tinum. 


Flatness or dull- 
ness over the lower 
part of both sides 
of the chest. The 
line of flatness al- 
most always 
changes with 
change of posture. 
Of course it is im- 
possible for both 
pleural cavities to 
be completely 
filled. 


As in pleurisy 
with moderate ef- 
fusion. There is 
rarely, however, 
well-marked bron- 
chial respiration, 
as, the disease being 
bilateral, sufficient 
compression to pro- 
duce bronchial res- 
piration could not 
often be compatible 
with life. 


Pulmonary 
(Edema. 




More or less dull- 
ness, generally dif- 
fused equally over 
the back of the 
chest on both sides, 
and most marked 
at the lowest parts. 


Weakened or 
suppressed. 

Rarely well- 
marked bronchial 
respiration. 



OF DISEASES OF THE LUNGS. 
TABLE NO. 10, Continued. 



59 



RALES. 


VOCAL 
RESONANCE. 


PALPATION. 


REMARKS. 


No exudation 


As in pleurisy 


Vocal fremitus 


Hydrothorax is 


of lymph and 


with moderate 


lessened or sup- 


bilateral ; while 


therefore no fric- 


effusion. 


pressed below the 
level of the liquid, 


the different 


tion sounds. 




kinds of pleurisy 






but increased above. 


are almost with- 
out exception 
unilateral. 


Subcrepitant 
and fine bubbling 


Variable. 


Vocal fremitus va- 


Like hydro- 




riable. 


thorax, pulmo- 


rales. 






nary oedema is a 
result of structu- 
ral disease of the 
heart or kidney. 
Although gen- 
erally bilateral, 
and then oftener 
found in the pos- 
terior portions, it 
may be unilateral 
and extend over 
one lobe or a 
whole lung. 



60 



THE PHYSICAL DIAGNOSIS 
TABLE NO. 10, Continued. 



Pneumo- 
hydkotho- 

KAX. 



INSPECTION AND 

MENSURATION. 



Expansion of 
affected side and 
relative mobility- 
impaired. Ob- 
literation and 
sometimes bulg- 
ing of intercostal 
depressions. 



PERCUSSION. 



Flatness at the base 
of the chest on the 
affected side, if there 
be enough liquid (se- 
rum or pus). Over 
the upper part of the 
same side and some- 
times extending be- 
yond the sternum, 
tympanitic resonance 
almost as intense as 
that of a tympanitic 
abdomen. This is 
heard by conduction 
even below the level 
of the liquid, the lat- 
ter often extending 
twice as high as the 
line of flatness. 

The tympanitic res- 
onance extends over 
the whole side, if 
there be only a small 
amount of liquid. 
Change of posture 
always, in this dis- 
ease, changes relative 
position of flatness 
and tympanitic reso- 
nance. Sometimes 
there is amphoric res- 
o n a n c e. Dullness 
from the condensed 
lung may sometimes 
be detected at the 
summit of the chest 
behind. If the quan- 
tity of air or gas be 
very large, on account 
of the extreme tension 
there may be tympa- 
nitic dullness. 



RESPIRATION. 



Suppressed be- 
low the level of the 
liquid. Feeble, dis- 
tant or suppressed 
above, unless there 
is a free communi- 
cation between the 
bronchial tubes and 
the pleural cavity 
above the level of 
the liquid, when 
there may be heard 
amphoric respira- 
tion, limited to a 
circumscribed area 
near the perfora- 
tion, which is gen- 
erally between the 
third and sixth ribs 
on the postero-lat- 
eral surface of the 
chest. 

Bronchial respi- 
ration over the con- 
densed lung (which 
is generally also 
tuberculous), at the 
top of the chest 
behind. 

Respiration on 
healthy side exag- 
gerated. 



OF DISEASES OF THE LUNGS. 
TABLE NO. 10, Continued. 



61 



Metallic tink- 
ling, and splash- 
ing or Hippo- 
cratic succussion 
sound. 



VOCAL, 

RESONANCE. 



Above the liquid 
' loric whisper, 
voice, and cough, if 
there is amphoric 
respiration. Or the 
vocal resonance may 
be feeble or wanting. 
Always wanting be- 
low the liquid. Me- 
tallic tinkling. 

Increased vocal res- 
onance or bronchoph- 
ony over the com- 
pressed lung at the 
top of the chest be- 
hind. 



PALPATION. 



Vocal fremitus 
diminished or 
suppressed. 

Displacement 
of heart. Fluc- 
tuation. Sense 
of elasticity 
above and of re- 
sistance below 
the level of the 
liquid. 



JVhen this dis- 
ease occurs, it is 
generally a com- 
plication of 
phthisis. 

The relative 
proportion of air 
or gas and water 
varies in different 
oases and in the 
same case at dif- 
ferent times, es- 
pecially if com- 
munication with 
the external air 
continues. 



62 



THE PHYSICAL DIAGNOSIS 
TABLE NO. 10, Continued. 



Pneumo- 
thorax. 



Emphy- 
sema. 



INSPECTION AND 
MENSURATION. 



As in the preceding. 



There is a character- 
istic deformity of the 
chest, a great bulging 
of the whole upper part 
generally, sternum and 
all. 

The anteroposterior 
diameter of the chest 
is greatly increased. 
The clavicles are ele- 
vated, and yet almost 
buried up. The lower 
parts of the scapulae 
sometimes project. The 
entire thorax is dragged 
upwards as one piece in 
inspiration, but there is 
little or no expansion 
of the chest, because the 
elasticity of the lung 
tissue being lost, expi- 
ration fails to empty the 
chest, and there is little 
room for the introduc- 
tion of fresh air. 

Eespiratory efforts 
labored and powerful, 
yet the breathing is 
chiefly abdominal, and 
the lower part of the 
chest may even sink in 
during inspiration. De- 
pression above clavicles 
in inspiration. 

The patient often 
stoops from anteropos- 
terior curvature of the 
spine. 

In a few cases of the 
variety called "senile 
atrophy " of the lung 
there is no bulging. 



PERCUSSION. 



Tympa n i t i c 
resonance over a 
part or the whole 
of the affected 
side, sometimes 
even extending 
to the right or 
left beyond the 
sternum. 



Exaggera ted 
resonance (some- 
times called ves- 
i c u 1 o-t y m p a- 
nitic), on both 
sides, but gen- 
erally greater 
on the left. It is 
heard over a 
greater area than 
the vesicular res- 
onance in health, 
as the diaphragm 
is pushed down 
and the heart is 
more or less com- 
pletely covered 
by lung. Owing 
to the slight 
movement of the 
lungs, this area 
is not much af- 
fected by forced 
inspiration or ex- 
piration. 

If the lower 
lobes are em- 
physematous, the 
line of hepatic 
flatness may be 
lowered to the 
ninth or tenth 
rib on the per- 
pendicular mam- 
mary line. 

In exceptional 
cases, there may be 
some dullness on 



RESPIRATION. 



Kespiration sup- 
pressed where the • 
air is, or it may be 
amphoric if there is 
free communication 
between the bron- 
chial tubes and the 
pleural cavity. Bron- 
c h i a 1 respiration 
over the condensed 
lung. Exaggerated 
on the healthy side. 



Weakened or 
suppressed over the 
upper lobes, more 
so usually on the 
left than on the 
right side. Inspi- 
ratory sound short- 
ened and expiration 
remarkably pro- 
longed, though of 
the same quality 
as in health. 



OF DISEASES OF THE LUNGS. 
TABLE NO. 10, Continued. 



63 



If bronchitis 
and asthma co- 
exist, bubbling 
rales, and oft- 
ener sibilant 
and sonorous 
rales. 



VOCAL 
RESONANCE. 



Diminished or sup- 
pressed where the air 
is, or amphoric voice, 
whisper, and cough, 
if there is amphoric 
respiration. Vocal 
resonance increased 
over the condensed 
lung, or even bron- 
chophony. 



Vocal resonance 
variable. 



PALPATION. 



Vocal fremitus 
diminished or 
suppressed where 
the air is, but 
increased over 
the condensed 
lung. Displace- 
ment of heart. 



Vocal fremitus 
variable. 

Heart's im- 
pulse lowered, 
sometimes being 
felt in the epi- 
gastrium instead 
of in the pre- 
cordial space. 

Chest walls un- 
usually elastic 
to the finger. 



A very rare dis- 
ease, air or gas 
■without liquid almost 
never being found 
in the chest. 

Pneumo-hydrotho- 
rax is often loosely 
called pneumotho- 
rax, however. 



In the great ma- 
jority of cases, 
vesicular emphy- 
sema has associ- 
ated with it chronic 
bronchitis. It is 
often accompanied 
by paroxysms of 
asthma. 

Generally a bilat- 
eral disease, al- 
though there is 
usually more affec- 
tion of the left 
lung than of the 
right. 



64 



THE PHYSICAL DIAGNOSIS 
TABLE NO. 10, Continued. 



Asthma. 



INSPECTION AND 

MENSURATION. 



Often a bulg- 
ing of the upper 
part of the chest, 
and a sinking in, 
during inspira- 
tion, of the lower 
part, on account 
of the emphy- 
sema which gen- 
erally coexists. 

Labored res- 
piration. 



Bronchitis. 

(Affecting the 



PERCUSSION. 



Owing to the 
commonly coexist- 
ing emphysema, 
there is generally 
exaggerated per- 
cussion resonance, 
as in that disease. 



Healthy reso- 
nance on both 
sides of the chest. 
A negative sign, 
but a good one 



Rarely a slight dull- 
ness at the lower part 
of the back of the 
chest, from excessive 
secretion which can- 
not be raised, or from 
collapse of pulmonary 
lobules from obstruc- 
tion of bronchial 
tubes. 



RESPIRATION. 



Diminished or sup- 
pressed. 

Sometimes exag- 
gerated. 

Jerking. 



In many cases nor- 
mal. 

Sometimes ob- 
scured by the rales, 
sometimes weakened 
or suppressed over a 
part of the chest by 
plugs of mucus in 
tubes, suddenly reap- 
pearing after cough- 
ing, sometimes by 
thickening of the 
mucous membrane ; 
but from this latter 
cause both sides are 
affected alike. 



OF DISEASES OF THE LUNGS. 
TABLE NO. 10, Continued. 



65 



Loud sibilant and 
sonorous rales with in- 
spiration and expira- 
tion (the sibilant, 
however, being more 
abundant in inspira- 
tion, and the sonorous 
in expiration), all over 
the chest on both 
sides and often heard 
at a distance. 

Sometimes bubbling 
rales towards the close 
of the paroxysms and 
for several days after, 
when they cease, un- 
less chronic bronchitis 
coexists. 



On hoth sides of the 
chest, especially over 
the lower lobes be- 
hind, sonorous and sib- 
ilant rales, according 
to the size of the tubes 
in which they are pro- 
duced, are sometimes 
heard alone, before 
secretion takes place, 
and after this mingled 
with coarse and fine 
bubbling rales. In 
many cases no rales 
are heard at all, and 
when present they of- 
ten shift their posi- 
tion. The moist rales 
are not heard unless 
the mucus is unusual- 
ly thin and abundant, 
which is not the case 
in many instances. 
They occur oftener 
in chronic than in 
acute bronchitis, he- 
cause in the former 
the liquid is more apt 
to be muco-purulent, 
and therefore pro- 
duces better bubbles. 
They occur oftener 
also in young chil- 
dren than in adults, 
because the former 
expectorate less. 



VOCAL 
RESONANCE. 



PALPATION. 



Sometimes a 
rhonchial fremi- 
tus. 



REMARKS. 



The physical 
signs given are 
those of a parox- 
ysm. This is 
generally accom- 
panied by a tem- 
porary emphyse- 
matous condition 
at least, and by 
bronchitis. 

Regular asth- 
matics often have 
these for perma- 
nent complica- 
tions. 



A bilateral dis- 



66 



THE PHYSICAL DIAGNOSIS 
TABLE NO. 10, Continued. 



DISEASE. 


INSPECTION AND 
MENSURATION. 


PERCUSSION. 


RESPIRATION. 


Capillary 
Bronchitis. 

(Including catar- 
rhal pneumonia.) 


If there is con- 
siderable collapse 
of pulmonary lob- 
ules, with emphy- 
sema, and with or 
without catarrhal 
pneumonia, the up- 
per part of the 
chest is more or 
less expanded, and 
the lower part may 
even sink in during 
inspiration. 


Undiminished res- 
onance on both 
sides of the chest, 
except sometimes 
when there is col- 
lapse of pulmonary 
lobules with or 
without catarrhal 
pneumonia, when 
there may be some 
circumscribed dull- 
ness over dissemi- 
nated portions of 
the lung, especially 
over the lower 
lobes behind, and 
exaggerated reso- 
nance in other 
parts, especially 
the upper part of 
the chest in front, 
if emphysema co- 
exists. 


Eespiration weak- 
ened or obscured by 
rales. If solidifica- 
tion from collapse 
coexists (with or 
without catarrhal 
pneumonia), bron- 
cho-vesicular or 
bronchial or weak- 
e n e d respiration 
over such parts. If 
emphysema coex- 
ists, weak or sup- 
pressed inspiration 
in front above, and 
expiration length- 
ened. 


Plastic 
Bronchitis. 

(Pseudo-mem- 
branous.) 




No dullness un- 
less from collapse, 
or from great 
quantity of liquid 
in bronchi. 


There may be 
suppression of res- 
piration over parts 
of the chest from 
the exudation or 
from collapse ; or 
broncho - vesicular 
or bronchial respi- 
ration from col- 
lapse. 



OF DISEASES OF THE LUNGS. 
TABLE NO. 10, Continued. 



67 



KALES. 


VOCAL, 

RESONANCE. 


PALPATION. 


REMARKS. 


Subcrepitant rales 
uniformly present on 
both sides of the chest, 
with either or both 
respiratory acts, es- 
pecially over the 
lower third of the 
chest behind. 

Sibilant and sono- 
rous, especially sibi- 
lant rales, and also 
fine and coarse bubbling 
rales may be heard all 
over the chest on both 
sides when the smaller 
and larger tubes are 
also affected. 


If solidifica- 
tion from col- 
lapse exists, with 
or without catar- 
rhal pneumonia, 
increased vocal 
resonance or 
broncho phony 
over such parts. 


If solidifica- 
tion from col- 
lapse exists, with 
or without catar- 
rhal pneumonia, 
increased vocal 
fremitus over 
such parts. 


A bilateral dis- 
ease. Inflamma- 
tion of the larger 
tubes generally 
coexists. Capil- 
lary bronchitis is 
sometimes attend- 
ed with collapse 
o f pulmonary 
lobules and ca- 
tarrhal pneumo- 
nia, especially in 
infants or in aged 
or feeble persons. 
Collapse, by the 
law of compen- 
sation, generally 
gives rise to 
emphysema in 
other portions of 
the lung. 


Sonorous and sibi- 
lant rales on both 
sides. 

Subcrepitant rales 
limited to certain por- 
tions of chest. Also 
bubbling rales. 

There may be tem- 
porary suppression of 
rales over parts of the 
chest from the exuda- 
tion, or more lasting 
suppression from col- 
lapse. 


As in the pre- 
ceding. 


As in the pre- 
ceding. 


A rare disease. 

The fibrinous 
exudation com- 
mences in the 
minute branches 
and extends up- 
wards. A few or 
many tubes may 
be affected. Col- 
lapse of pulmo- 
nary lobules may 
occur from ob- 
struction. 

Bilateral dis- 
ease. Either 
acute or chronic. 



68 



THE PHYSICAL DIAGNOSIS 
TABLE NO. 10, Continued. 



DISEASE. 


INSPECTION AND 
MENSURATION. 


PERCUSSION. 


RESPIRATION. 




Sometimes cos- 


There may be a slight 


We akened 




tal movements 


dullness. 


somewhat over 


Acute Lobar 


on affected side 




the cong e s t e d 


or Croupous 


diminis h e d on 




lobe. 


Pneumonia. 


account of pain. 






First Stage. 








(Congestion.) 










Costal move- 


Over the affected lobe 


Broncho-vesicu- 




ments d i m i n- 


or lobes increased sense 


lar followed by 




ished on affected 


of resistance and 


bronchial respira- 
tion, as solidifi- 




side (especially 


marked dullness, some- 




if the whole lung 


times even amounting 


cation increases. 




be inflamed), and 


to flatness. The inter- 


Exaggerated 




increased on the 


lobar fissure can be dis- 


on healthy side. 




other side. 


tinctly mapped out by 






There may be 


percussion, if one or 






in some cases a 


two lobes of the affected 






slight increase by 


lung remain unaffected, 




Second Stage. 


measurement. 


the latter giving forth 
an exaggerated reso- 
nance. In such cases 




(Hepatization.) 










the resonance over the 








healthy lung is i n- 








ereased, but not so much 








as over these unaffected 








lobes. 

In some cases, instead of 
the usual dullness there may 
be tympanitic or cracked- 
metal or amphoric reso- 
nance over part of an upper 
solidified lobe, this quality 
coming from the air in the 
trachea or bronchi, con- 
ducted by the solidification; 
also sometimes at the base 
of the chest, if affected, be- 
ing conducted upwards from 
the stomach or colon. 





OF DISEASES OF THE LUNGS. 
TABLE NO. 10, Continued. 



RALES. 


VOCAL RESONANCE. 


PALPATION. 


REMARKS. 


Generally, but 
not invariably, the 
crepitant rale. 
When it does occur, 
it is pathognomonic. 

Rarely dry and moist 
bronchial rales from 
accompanying circum- 
scribed bronchitis, or a 
friction sound from 
secondary pleurisy. 






Generally a uni- 
lateral disease. 
More common in a 
lower lobe, espe- 
cially on the right 
side. When so situ- 
ated, the physical 
signs are best heard 
in the infra-scapu- 
lar and infra-axil- 
lary regions. 


Crepitant rale dis- 
appears, but occa- 
sionally it persists 
even in this stage, a 
few air-cells here 
and there not being 
filled with exuda- 
tion. 

Barely moist bron- 
chial rales. 


Increased vocal 
resonance and in- 
creased bronchial 
whisper, followed 
by bronchophony and 
whispering bron- 
chophony, as solidi- 
fication increases. 

Occasionally pec- 
toriloquy and 
whispering pecto- 
riloquy. 


Vocal fremi- 
tus generally 
increased over 
affected por- 
tion, but some- 
times dimin- 
ished, and oc- 
casionally ab- 
sent, owing to 
plugging of 
bronchi or 
pleuritic effu- 
sion. 


Sometimes the 
heart's sounds are 
transmitted with 
peculiar dist i n c t- 
ness through the 
solidification, some- 
times not. 



70 



THE PHYSICAL DIAGNOSIS 
TABLE NO. 10, Continued. 



DISEASE. 


inspection and 
mensuration. 


PERCUSSION. 


RESPIRATION. 


Croupous 
Pneumonia. 

Third Stage. 

(1.) Resolution. 

or 


G r a d u a 1 re- 
turn to the nor- 
mal condition, 
and after recov- 
ery even contrac- 
tion may occur 
in some cases. 


Dullness grad- 
ually disappears. 
A little, however, 
often remains for 
a long time. 


The bronchial 

merges into the bron- 
cho-vesicular respira- 
tion, which is followed 
for some time after 
recovery by weakened 
respiration. 


(2.) Purulent 
infiltration. 




Dullness con- 
tinues, and be- 
comes more 
marked. 


Bronchial respira- 
tion, or feeble or sup- 
pressed respiration. 


Catarrhal 
Pneumonia. 

(Lobular or broncho- 
pneumonia.) 


Already 


explained in 


connection with 


Interstitial 

or 
Chronic Pneu- 
monia, 
or 
Fibroid Phthi- 
sis. 


Difference in 
the relative cos- 
tal movements 
on the two sides, 
and after a while 
contract ion of 
the affected lobe. 


Marked dull- 
ness. 

Occasionally a 
tympanit i c reso- 
nance. 


Bronchial or bron- 
cho-vesicular. 



OF DISEASES OF THE LUNGS. 
TABLE NO. 10, Continued. 



71 



Subcrepitant 
rale appears, with 
sometimes a few 
fine and coarse 
bubbling rales. 
Crepitant rale re- 
turns. 



Fine and coarse 
bubbling rales 
generally in 
abundance- 



Capillary 



Fine and coarse 
bubbling rales, 
also sibilant and 
sonorous rales. 



VOCAL 

RESONANCE. 



Bronchophony 
and whispering 
bronchop h o n y, 
followed by in- 
creased vocal 
resonanc e and 
increased bron- 
chial wh i s pe r, 
and this by nor- 
mal vocal reson- 
ance and whisper. 



"Weak bron- 
chophony or di- 
minished vocal 
resonance. 



Bronchitis. 



Increased vo- 
cal resonance 
and incre a s e d 
bronchial whis- 
per. 

Bronchophony 
and whispering 
bronchophony. 



PALPATION. 



Increa sedvo- 
cal fremitus, fol- 
lowed by the nor- 



Vocal fremitus 
variable. 



Increased vo- 
cal fremitus. 



If, as very rarely 
happens, an abscess 
forms and discharges, 
it may give rise to the 
same physical signs 
as a phthisical cavity 
(which see). 



Limited to lobules 
scattered through 
lung substance i n 
patches varying i n 
size from a hemp seed 
to an egg, or larger. 



Called also Cirrho- 
sis of Lung. It 
leads to contraction 
of the lung and dila- 
tation of the bronchi, 
and is always accom- 
panied by bronchitis. 
A unilateral disease. 
Occurs among stone 
masons, grinders, etc. 
This disease is "the 
anatomical basis of 
almost all pulmonary 
phthisis." 



72 



THE PHYSICAL DIAGNOSIS 
TABLE NO. 10, Continued. 



DISEASE. 


inspection and 

mensuration. 


PERCUSSION. 


RESPIRATION. 


Acute 
Miliary 
Tuberculo- 
sis. 




When one lung 
is affected a little 
more than the 
other, there may- 
he a slight excess 
of dullness in the 
former. But oft- 
ener there is no 
notable dullness on 
either side, the 
granulations, even 
when very numer- 
ous, remaining iso- 
lated. 




Phthisis. 

First Stage. 
(Incipient.) 




Some dullness, es- 
pecially if the de- 
posit he at all 
superficial, at the 
summit of the chest 
on one side (more 
often the left), in 
front or behind. 

There may be 
vesiculotympanitic 
resonance at the 
apex from second- 
ary lobular emphy- 
sema. 

Remember the 
possible very slight 
dullness in health 
on the right side. 
It is in connection 
with the diagnosis 
of incipient 
phthisis that this 
fact becomes of the 
most importance. 

Any dullness, 
however slight, at 
the left apex is al- 
ways abnormal. 


Respiration 
weakened or bron- 
cho-vesicular, occa- 
sionally jerking. 

[There may be 
abnormal trans- 
mission of the 
heart sounds 
(available in the 
infra-clavicular re- 
gion), denoting a 
deposit on the right 
side, if the first 
sound be heard 
better here than on 
the left; and on 
the left side, if the 
second sound be 
heard better here 
than on the right.] 



OF DISEASES OF THE LUNGS. 
TABLE NO. 10, Continued. 



73 



KALES. 


VOCAL 

KESONANCE. 


PALPATION. 


EEMAKKS. 


Subcrepitant, fine and 
coarse bubbling, and 
sibilant and sonorous 
rales in different places 
all over both sides. 






The trouble 
is apt to be 
found about 
equally d i f - 
fused in both 
lungs. This 
disease is lia- 
ble to be con- 
founded with 
typhoid fever. 


There may be one or 
more of the following 
kinds of rales : — 

1. Subcrepitant, indi- 
cating a circumscribed 
capillary bronchitis 
about the deposit. 

2. Crepitant, here oft- 
en called crackling, in- 
dicating a circumscribed 
pneumonia. 

3. Rubbing friction 
sounds, here often called 
crumpling, indicating a 
circumscribed dry pleu- 
risy. 

4. Sibilant rales, indi- 
cating a spasm of the 
tubes, or circumscribed 
bronchitis. 

All these rales derive 
their significance from 
being heard at the apex 
(oftener the left). 


Increased bron- 
chial whisper. 

Increased vo- 
cal resonance. 

Remember the 
possible normal dis- 
parity. 


Increased vo- 
cal fremitus. 





74 



THE PHYSICAL DIAGNOSIS 
TABLE NO. 10, Continued. 



DISEASE. 


inspection and 

mensuration. 


PERCUSSION. 


RESPIRATION. 


Phthisis. 

Second Stage. 


Some flattening 
and deficient ex- 
pansion of the up- 
per part of chest 
on one side. 
Marked diminu- 
tion in size of chest 
by mensuration. 


Dullness, more or 
less, at upper part 
of chest on affect- 
ed side. 

Or tympanitic 
resonance (c o n- 
ducted from bron- 
chi, as there are no 
cavities yet). 

There may be 
exaggerated reso- 
nance from coex- 
isting lobular em- 
physema. 


Bronchial or bron- 
cho-vesicular or 
weakened respira- 
tion. Occasionally 
jerking. (Abnor- 
mal transmission of 
heart sounds.) 


Third Stage. 
(Cavernous.) 


Extra ordinary- 
prominence of the 
clavicles from the 
falling in of upper 
parts of lung, and 
deficient expan- 
sion. 

Still greater dim- 
inution in size of 
chest by mensura- 
tion. 


Tympanitic reso- 
nance within cir- 
cumscribed spaces. 
Occasi onal ly 
cracked-metal or 
amphoric reso- 
nance. 

Dullness over 
the same space, if 
the cavity is full of 
morbid products, 
as, e. g., in the 
morning before 
copious expectora- 
tion. 


Cavernous respi- 
ration, especially af- 
ter an abundant ex- 
pectoration. If the 
cavities are quite 
small, the cavern- 
ous respiration may 
be drowned out by 
the neighboring 
bronchial respira- 
tion, or combined 
with it, forming a 
kind of broncho- 
cavernous respira- 
tion. Rarely am- 
phoric respiration. 


Dilatation 

OF THE 

Bronchi. 

(Bronchiectasis.) 


There may be 
some depression of 
the chest over the 
places affected. 


Generally dull- 
ness from the con- 
densed and con- 
tracted parenchy- 
ma, and also from 
accumulation of 
mucus. 

Sometimes tym- 
panitic or amphor- 
ic resonance, if the 
tubes are free from 
morbid products. 


Bronchial, if the 
tubes are cylindric- 
al and unobstruct- 
ed. 

Cavernous o r 
amphoric, if saccu- 
lar and. large 
enough. 



OF DISEASES OF THE LUNGS. 
TABLE NO. 10, Continued. 



75 



Fine and coarse bub- 
Ming rales, from soft- 
ened deposit or from 
accompanying c i r - 
cumscribed bronchitis, 
generally heard bet- 
ter in the morning 
before much expecto- 
ration. Also sibilant 
and sonoi-ous rales, 
friction sounds, and 
crepitant and subcrepi- 
tant rales may be heard. 



Gurgling. 

Very rarely metal- 
lic tinkling. 



Bubbling rales from 
mucus in dilated 
tubes ; sometimes even 
gurgling, if there is 
considerable dilata- 
tion. 



VOCAL 
RESONANCE. 



Increased 
vocal reso- 
nance and 
whisper, or 
bronchophony 
and whisper- 
ing bro ri- 
ch op hony. 
O c c a s ion- 
ally bron- 
choph o n i c 
pectoriloquy, 



Sometimes 
caver nous 
pectoriloquy 
and whis- 
pering pec- 
toriloquy. 

Amphoric 
voice when 
there is am- 
phoric res- 
piration. 



Increased 
vocal reso- 
nance and 
bronchoph - 
ony. 

Sometimes 
pectoril- 
oquy. 



PALPATION. 



Increased vocal 
fremitus. 



Increased vocal 
fremitus when the 
cavity is large, 
superficial, and has 
free communication 
with the bronchi. 
Sometimes gur- 
gling fremitus. 
When the disease 
exists principally 
in one lung, the 
shrinking of this 
lung sometimes 
drags the heart out 
of place. Pulsa- 
tion detected by 
palpation. 



Increased vocal 
fremitus. 



REMARKS. 



The accompany- 
ing signs are ob- 
served on the side 
first affected, gen- 
erally at the apex. 

By this time, 
however, signs de- 
noting a less ad- 
vanced condition of 
the disease may be 
heard at the apex 
of the other side. 



These cavernous 
signs (to be sought 
for especially in the 
upper part of the 
lung) often have 
in their vicinity 
many of the signs 
of solidification al- 
ready mentioned. 



Usually affects 
many bronchi, and 
occurs in both 
lungs. Most com- 
mon in the lower 
lobes and the mid- 
dle lobe of the right 
lung. Follows 
bronchitis, collapse 
of pulmonary lob- 
ules, pleurisy, and 
pneumonia, espe- 
cially interstitial 
pneumonia. The 
dilatation may be 
of three varieties, — 
cylindrical, f u s i- 
form, or saccular. 



76 



THE PHYSICAL DIAGNOSIS 
TABLE NO. 10, Continued. 



DISEASE. 


inspection and 

mensuration. 


PERCUSSION. 


RESPIRATION. 


Carcinoma 

of 

Lung. 


Diminished costal 
motion. Flattening 
and contraction of 
the affected side (if 
infiltrated). 

Or the growth may 
be so great (perhaps 
four or five pounds) 
as to enlarge the side. 

Effacement of in- 
tercostal depressions, 
if pleuritic effusion 
ensue. 


Dullness, often 
extending beyond 
the median line, 
with increased re- 
sistance, uniformly 
extending over a 
part or the whole 
of a lung, if infil- 
trated, but scat- 
tered, if there are 
nodules large 
enough to produce 
dullness. 


Bronchial or 
feeble or sup- 
pressed. (Sup- 
pressed by press- 
ure of cancerous 
deposit on a large 
bronchus.) 

If only one 
lung is affected, 
exaggerated res- 
piration over 
the healthy lung. 


Intra- 
thoracic 
Tumors. 

(Especially aneu- 
rism.) 


There may be a 
bulging or even per- 
foration of the ribs 
and sternum, with 
diminished respira- 
tory movements. 

Enlargement of 
chest not as uniform 
as when enlarged by 
liquid. Distention of 
superficial thoracic 
veins ; or of those of 
one or both upper 
extremities with 
cedema; or of those of 
one or both sides of 
the neck (significant 
if there is no tricus- 
pid regurgitation or 
dilatation of the right 
heart). 

Local pulsation, 
synchronous with 
heart's systole, some- 
times visible in aneu- 
rism. 


There may be 
dullness or flat- 
ness over the tu- 
rn o r (and over 
pleuritic effusion 
or compressed lung 
if they coexist). 
The dullness over 
an aneurism or 
mediastinal tumor 
always extends up- 
wards and to the 
right or left; in 
aneurisms espe- 
cially to the right. 
There must not be 
too forcible percus- 
sion over aneurism. 


Over the tumor 
weakened or sup- 
pressed from 
pressure, and 
bronchial over 
compressed lung, 
if there be any. 



OF DISEASES OF THE LUNGS. 
TABLE NO. 10, Continued. 



77- 



RALES. 


VOCAL 
RESONANCE. 


PALPATION. 


REMARKS. 


Bubbling rales, 
if softening takes 
place, or if there 
is secondary 
bronchitis. 


Increased 
vocal reso- 
nance and 
bronchoph - 
ony. 


Vocal fremitus at 
first increased, then 
diminished. 


A rare disease. 

Usually encepha- 
loid and associated 
with mediastinal can- 
cer. There are two 
varieties : — 

1. Secondary nodu- 
lar deposit, oftener af- 
fecting both lungs, the 
nodules varying in 
size from a pea to an 
orange. If few, small, 
and scattered, they 
may not give rise to 
any physical signs. 

2. Primary infiltra- 
tion into the air-cells, 
usually affecting one 
lung. Pleuritic effu- 
sion often coexists. 
Softening and exca- 
vation may ■ take 
place. 


There may be 
bubbling rales 
from secondary 
bronchitis, or 
from softening 
if the tumor is 
cancerous. 

There is often, 
but not always, 
heard over an an- 
eurism a systolic 
murmur, soft or 
harsh or roaring, 
and of variable 
intensity. Rare- 
ly there may be 
heard also a dias- 
t o 1 i c murmur, 
caused by the 
passage of blood 
out of the sac. 


Vocal res- 
onance va- 
riable. 
Bronchoph- 
ony over 
c o mpressed 
lung tissue, 
if there be 
any. 


Vocal fremitus di- 
minished or sup- 
pressed over tumor. 
Increased over com- 
pressed lung and pri- 
mary bronchi. 

Heart pulsations 
may often be felt out 
of place in conse- 
quence of the press- 
ure. The arteries on 
one side may be com- 
pressed more than on 
the other. Over an- 
eurism an impulse is 
felt synchronous with 
the heart's systole, 
sometimes stronger 
even than over the 
heart, sometimes 
double, either throb- 
bing or undulating. 
Often a purring thrill 
is felt, generally cir- 
cumscribed, but 
sometimes diffused 
over a large portion 
of the chest. 


These tumors are, 
in the great majority 
of cases, aneurisms ; 
but sometimes are 
cancerous, fibrous, or 
fatty tumors, which 
generally start from 
the mediastinum. 
They often exert 
great pressure (to 
their injury, of 
course) on the heart, 
lungs, nerves, or ves- 
sels, with character- 
istic symptoms. Tu- 
mors may be on one 
or both sides of chest. 
Pleuritic effusion may 
result, also collapse 
of pulmonary lobules 
or oedema. Aneu- 
risms arise most com- 
monly from the as- 
cending portion of 
the arch of the aorta. 



78 



THE PHYSICAL DIAGNOSIS 
TABLE NO. 11. 



The 
Healthy 
Heart. 



AUSCULTATION. 



Pericardi- 



First Stage. 

(Exudation of 
fibrin.) 



When heard over the apex, the 
two healthy heart sounds may be 
roughly represented by a trochee 
with dots marking the pauses, 
thus : ^ . . . The first or sys- 
tolic is accented, long, booming 
and of low pitch, and the second or 
diastolic sound is short and valvu- 
lar. At the base of the heart the 
two sounds may more nearly be rep- 
resented by an iambus -^, . — . . ., 
the second sound being here ac- 
cented and as long as, if not longer 
than, the first sound, and more in- 
tense. This is because the booming 
quality, caused by the " element of 
impulsion " or " muscular ele- 
ment," is not transmitted so far 
as the valvular element of the first 
sound. 



A characteristic friction sound, 
often lasting a few hours only, but 
sometimes for a few days, pro- 
duced by the rubbing together of 
the inflamed and roughened peri- 
cardial surfaces in the systolic and 
diastolic movements of the heart. 
It is either single or double, strictly 
accompanying or independent of 
the heart sounds, always super- 
ficial, and usually restricted to the 
prascordial space, — sometimes 
even to a part of it only. Heard 
with the greatest intensity on the 
left edge of the sternum on a level 
with the fourth rib. Quality graz- 
ing, crumpling, creaking, or rasp- 
ing, and either feeble or loud. In- 
tensity increased by bending the 
body forward so that the heart is 
brought nearer the chest walls. 
Also increased by firm pressure 
with the stethoscope ; also by a full 
inspiration, the pericardial surfaces 
being forced nearer together by the 
expanded lung. A single sound 
may be made double in this way. 



percussion. 



The space on the surface 
of the chest beneath which 
the heart lies is called the 
pracordia, or precordial 
region. That part of the 
prajcordia which is uncov- 
ered of lung is called the su- 
perficial cardiac space, and 
the rest, where lung tissue 
intervenes between the 
heart and chest walls, is 
called the deep cardiac 
space. The boundaries of 
each of these spaces must 
be carefully memorized. 
They are well shown on 
Plate I. 

The dullness over the 
deep cardiac space, though 
distinct, is of course much 
less than that over the su- 
perficial cardiac space. 



OF DISEASES OF THE HEART. 
TABLE NO. 11. 



79 



INSPECTION. 



The apex i m- 
pulse of the healthy- 
heart can f r e- 
quently, but not al- 
ways, be seen in the 
same place in which 
it is felt. 



Irrit able and 
forcible action of 
heart. 



PALPATION. 



The healthy apex beat in the sit- 
ting or standing posture is felt in 
the fifth intercostal space, but often 
in the fourth when lying on the 
back. It is felt over an area an 
inch in diameter, from half an inch 
to two inches to the right of the 
linea mammalis (a vertical line 
drawn through the left nipple), and 
about three inches, on an average, 
to the left of the median line. When 
lying on the right side, the centre 
of the area is about half an inch 
nearer the sternum, and when lying 
on the left side it is felt on the linea 
mammalis. In some persons the 
apex beat cannot be felt at all, espe- 
cially when lying on the right side. 
It is felt better when on the back, 
still better when sitting, and best 
of all when on the left side. 



Forcible action of heart and fric- 
tion fremitus. 



Tor purposes of 
compari son, the 
signs of the 
healthy heart are 
placed here. 

A thorough 
knowledge of the 
healthy heart is an 
absolutely indispen- 
sable prerequisite to 
an understanding of 
the diseased organ. 



Endocarditis with 
its physical signs 
often coexists. 
Rheumatic pericar- 
ditis, which occurs 
perhaps once in 
every six cases of 
rheumatic fever, 
is almost always ac- 
companied by endo- 
carditis. 



80 



THE PHYSICAL DIAGNOSIS 
TABLE NO. 11, Continued. 



DISEASE. 


AUSCULTATION. 


PERCUSSION. 


Pericar- 
ditis. 

Second 
Stage. 

(Serous ef- 
fusion.) 


Friction sounds generally (but 
not invariably) disappear when 
the effusion becomes considera- 
ble ; often remaining, however, 
at the base of the heart near the 
large vessels, and sometimes be- 
ing distinctly heard all over the 
prascordia, in spite of the effu- 
sion, by bending the body for- 
wards. Heart sounds, especially 
the first, now feeble and distant, 
or absent altogether. Absence 
of respiratory murmur and vocal 
resonance over the enlarged area 
caused by the distention of the 
pericardial sac, the distention 
pushing the lungs to the right 
and left. 

During absorption the friction 
sounds reappear and may last a 
week or more ; and the heart 
sounds become more distinct. 


With large effusion, the area of 
precordial dullness is greatly in- 
creased vertically and laterally, 
and in the upright posture it be- 
comes pyramidal in shape, corre- 
sponding to the form of the dis- 
tended sac, whose base is near the 
sixth intercostal space, and apex 
near the sternal notch, and which 
may extend laterally almost from 
one nipple to the other. 

In chronic pericarditis with very 
large effusion and dilatation of the 
sac, the dullness or flatness may 
extend nearly to the axillary and 
infra-axillary regions on each side. 
The dullness from the liquid ex- 
tends below the point of the apex 
beat. The anterior portion of the 
sac is mostly uncovered of lung 
and in contact with the chest walls. 
When the patient lies down, the 
lateral diameter of dullness is in- 
creased at the expense of the ver- 
tical. 

If the effusion is small, there is 
merely an increase in the lateral 
diameter of dullness at the lower 
portion of the prsecordial region 
in the upright posture. 

Gradual diminution of the area 
of dullness as convalescence ap- 
proaches. 


Endo- 
cardi- 
tis. 


A systolic murmur, generally 
soft and feeble, due to thickening 
or roughening of the inflamed en- 
docardium, heard sometimes at 
the aortic orifice, but usually at 
the apex. The swollen mitral 
valves with shortened chords may 
be slightly insufficient, but usu- 
ally the murmur is mitral non-re- 
gurgitant, caused by intraventric- 
ular roughness. 

Auscultation of the heart should be 
practiced at the beginning of every case 
of rheumatic fever, to make sure that 
there is no old valvular lesion which 
might be mistaken for a recent endo- 
carditis. If there be an old valvular 
murmur, there will be more or less 
cardiac hypertrophy, and the murmur 
may be loud and rough. 





OF DISEASES OF THE HEART. 
TABLE NO. 11, Continued. 



81 



INSPECTION. 


PALPATION. 


KEMARKS. 


Arching forward of 
the precordial region 
(mostly in young peo- 
ple, whose costal carti- 
lages are pliable), often 
extending from the sec- 
ond to the sixth intercos- 
tal space. The effusion, 
if large, restrains the 
respiratory movement 
on the left side. 


The point of the apex 
beat raised and carried 
to the left of its normal 
position. Friction 
fremitus disappears. 

Apex beat feeble, or 
imperceptible, if effu- 
sion is large. 


Usually the effusion lasts 
about a week or ten days 
in acute cases. 

Hydro-pericardium has 
physical signs which do 
not materially differ from 
those of pericarditis, ex- 
cept that there is no fric- 
tion sound. 


At first the area of 
the visible impulse of 
the heart is increased, 
but later it is apt to be 
indistinct. 

Irregular beating. 


At first violent and 
excited action, after- 
ward weakened. 


Occurs in the great ma- 
jority of instances as a sec- 
ondary affection in the 
course of acute articular 
rheumatism. It is more 
common than pericarditis, 
with which it is often asso- 
ciated, being far oftener 
observed without pericar- 
ditis than the latter is with- 
out it. 

It may occur in the es- 
sential and exauthematous 
fevers, in pyemia, Bright's 
disease, diphtheria, etc. 



82 



THE PHYSICAL DIAGNOSIS 
TABLE NO. 11, Continued. 



Hypertrophy 

of THE 
Left Heart. 



AUSCULTATION. 



First sound loud, dull, and 
prolonged. Aortic second 
sound exaggerated, if there 
are no valvular lesions. Ab- 
sence or great diminution of 
vocal resonance over a larger 
area than normal, showing 
an enlarged superficial car- 
diac space. This sign is es- 
pecially available in females 
with large breasts, where 
percussion is difficult. 



percussion. 



Extension of percussion 
dullness to the left, and down- 
wards in the direction of the 
apex, especially the latter. 
Superficial cardiac space in- 
creased (the lung being pushed 
to the left), and greater degree 
of dullness over it than in 
health. This increase must 
not be confounded with that 
produced by retraction of the 
lung from its own diseases. 



Hypertrophy 

of THE 
Right Heart. 



First sound loud, dull, and 
prolonged (except in some 
cases of extensive emphy- 
sema, where the edges of the 
lungs by overlapping the 
heart partially muffle the 
sound), heard with greatest 
intensity near the ensiform 
cartilage. 

Exaggeration of the pul- 
monary second sound, espe- 
cially if there is obstruction 
to the pulmonary circula- 
tion. Auscultation of the 
voice available as in the 
preceding. 



Some extension of 
to the right of the normal 
dullness, but not in propor- 
tion to the amount of the en- 
largement of the heart, the 
increased area of dullness 
being mostly to the lefi. 

There is often dullness over 
the second and third right 
cartilages near the sternum, 
owing to the enlarged right 
auricle. 



OF DISEASES OF THE HEART. 
TABLE NO. 11, Continued. 



INSPECTION. 



Increased area of visi- 
ble impulse, extending 
over several intercostal 
spaces and sometimes 
over the whole of the 
prsecordia. In children 
there is often an abnor- 
mal projection of the 
precordial region. Apex 
beat seen to be lower and 
farther to the left than 
* normal. If it cannot be 
seen, it can almost al- 
ways be felt. If not, it 
can be located by auscul- 
tation. 



Increased area of im- 
pulse and abnormal pro- 
jection as above. 

Strong epigastric im- 
pulse seen as well as felt, 
often shaking the lower 
part of the sternum and 
extending more or less 
over the liver. 



PALPATION. 



Apex beat is felt in 
the sixth, seventh, 
eighth, or even ninth in- 
tercostal space, and to 
the left of the linea 
mammalis, the down- 
ward displacement being 
especially marked. It 
is powerful and distinct, 
though sluggish. 

A powerful heaving 
movement is felt all over 
the prascordia. 



. Apex beat is felt far- 
ther to the left generally 
than in left side hyper- 
trophy (perhaps one, 
two, or even three inches 
to the left of the nip- 
ple), but not so far down, 
the lower border of the 
heart being almost hori- 
zontal. 

Apex beat sometimes 
feeble on account of the 
apex becoming rounded 
or blunted. Even then 
there will be strong im- 
pulse in the intercostal 
spaces above the apex. 

Powerful heaving 
movement all over the 
precordia. 



When the whole heart is 
hypertrophied, the physical 
signs of left and right side 
hypertrophy are combined 
in varied proportions. 

In the great majority of 
cases of cardiac hypertro- 
phy, valvular lesions coex- 
ist, and are accompanied by 
their respective murmurs. 
When there are no valvular 
lesions, chronic B right's dis- 
ease is the most common 
cause of left heart hyper- 
trophy. 



Pulmonary emphysema 
is the most common cause 
of right heart hypertrophy, 
when there are no valvular 
lesions. 

If the apex cannot be 
felt, its location can be as- 
certained by finding by aus- 
cultation the spot where the 
first sound has the greatest 
intensity. 



84' 



THE PHYSICAL DIAGNOSIS 
TABLE NO. 11, Continued. 



Dilatation op 
the Heart. 



AUSCULTATION. 



First sound short, feeble, 
and valvular, lacking par- 
tially or entirely the element 
of impulsion or muscular 
element, thus resembling 
the second sound. Second 
sound often inaudible at the 
apex. Irregular pauses, or 
intermissions of the beat, 
especially on exertion. If 
a murmur has previously 
existed, its rhythm may 
become lost, and it may 
become impossible to say 
whether it is synchronous 
with the first or second 
sound. This is called asys- 
tolism. 

Eespiratory murmur di- 
minished in intensity over 
the upper part of the left 
lung. 



PERCUSSION. 



Area of dullness is in- 
creased in every direction, 
especially laterally, the trans- 
verse diameter greatly ex- 
ceeding the vertical. The 
shape of the dullness is oval 
or square instead of the nor- 
mal triangular dullness. 

An upward and lateral in- 
crease of dullness at the base 
of the enlarged heart indi- 
cates dilated auricles. 



OF DISEASES OF THE HEART. 
TABLE NO. 11, Continued. 



85 



INSPECTION. 



The area of visible 
impulse is increased, but 
it is indistinct. 

In persons with thin 
chest walls an undulat- 
ing motion over the 
prascordia may be visi- 
ble. 



PALPATION. 



Feeble cardiac im- 
pulse. No heaving move- 
ment, but weak undu- 
lating motion over the 
whole prascordia. 

A queer sensation of 
rolling over, a kind of 
diffused tumble against 
the chest walls followed 
by a pause. 

Apex beat not so low 
as in hypertrophy. 



In a great many cases 
hypertrophy and dilatation 
are combined in varied pro- 
portions, so that we have 
enlargement with predom- 
inating hypertrophy or en- 
largement with predomi- 
nating dilatation. Hyper- 
trophy precedes dilatation 
with rare exceptions ; if the 
enlargement be very great, 
dilatation predominates. 

From the accompanying 
physical signs under hyper- 
trophy and dilatation, it can 
generally be determined 
which predo rainates, to 
what extent, and which side 
(if either) is more particu- 
larly affected. 

Hypertrophy is more es- 
pecially the characteristic 
of the left ventricle, and 
dilatation of the right ven- 
tricle, although either may 
affect both. 



86 



THE PHYSICAL DIAGNOSIS 
TABLE NO. 11, Continued. 



VALVULAR 
LESIONS. 

/. Left Heart. 



Aortic Ob- 
struction. 

(Stenosis.) 

[2-] 

Numbers in 
brackets repre- 
sent order of 
frequency ac- 
cording to 
Waleho. 



AUSCULTATION. 



Rhythm of 
Murmur. 



Systolic. 



Maximum Inten- 
sity of Murmur. 



Second right 
intercostal 
space, near the 
sternum. 

Exceptionally 
second left inter- 
costal space near 
the sternum. 



Murmur 
also heard. 



Over the ca- 
rotids, more or 
less over the 
body of the 
heart, some- 
times in the 
interscapul a r 
space near the 
spinous ridge 
of the scapula, 
feebly or not 
at all at the 
apex. 

Transmitted 
better upwards 
than down- 
wards. 



Other things to 
be noticed. 



Murmur gen- 
erally soft, but 
may be rough 
or musical, and 
it always more 
or less ob- 
scures the first 
sound of the 
heart. 

Aortic second 
sound weak- 
ened and in- 
distinct in pro- 
portion to the 
amount of ob- 
struction. 

Aortic re- 
gurgitation is 
often asso- 
ciated, when 
there is a dis- 
tinct double 
murmur heard 
over a large 



OF DISEASES OF THE HEART. 87 

TABLE NO. 11, Continued. 



PERCUSSION. 


INSPECTION. 


PALPATION. 


REMARKS. 


Hypertrophy of 


See Left 


See Left 


Aortic obstruction is a 


the left ventricle 


Heart Hyper- 


Heart Hyper- 


very common form of 


is induced after 


trophy and 


trophy and 


heart disease. Besides 


the obstruction 


Dilatation. 


Dilatation. 


the very frequent associa- 


has existed for a 






tion of aortic regurgita- 


while, and there- 






tion, it may induce after 


fore is found in 






awhile mitral insufficiency. 


the majority of 






It is most frequently met 


cases which come 






with in middle or ad- 


under observa- 






vanced life. 


tion. 






It has to be diagnostica- 


Finally dilata- 






ted from an inorganic aortic 


tion may ensue. 






murmur which is not un- 


See percussion 






common in ancemia. This 


signs under Left 






and the other inorganic 


Heart Hyper- 






murmur — the pulmonic 


trophy and Dila- 






— are always systolic. 


tation. 






The distinguishing feat- 
ures of the inorganic aortic 
murmur are : — 

Uniformly soft and fee- 
ble, not constant, not pro- 
ductive of cardiac enlarge- 
ment, accompanied by a 
continuous hum in jugular 
veins (with sometimes a 
musical intonation), called 
" bruit de diable," which is 
suspended by pressure 
over the veins with the fin- 
ger, and by symptoms of 
anaemia (which is more 
common among females 
than males) ; the aortic 
second sound as intense as 
normal, and never accom- 
panied by aortic regurgi- 
tation. 

Sometimes there may be 
an innocuous murmur, not 
inorganic but produced by 
mere roughness not suffi- 
cient to cause obstruction, 
and consequently not fol- 
lowed by cardiac enlarge- 








ment. 



88 



THE PHYSICAL DIAGNOSIS 
TABLE NO. 11, Continued. 





auscultation. 


DISEASE. 










Rhythm of 


Maximum Inten- 


Murmur 


Other things 




Murmur. 


sity of Murmur. 


also heard. 


to be noticed. 




Diastolic. 


Second right 


Diffused 


Murmur gen- 






intercostal 


over a large 


erally soft, but 






space (or 


area, extend- 


may be rough 






fourth left cos- 


ing in the di- 


or musical. It 






tal cartilage), 


rection of the 


replaces or im- 


Aortic 
Regurgita- 




near the ster- 


apex or ensi- 


mediately fol- 




num. 


form cartilage, 


lows the aortic 






and heard at 


second sound, 


tion. 






the sides of 


which is weak- 


(Insufficiency.) 






the chest and 
along the spine. 


ened or sup- 
pressed. 


[3-] 






Transmitted 


Aortic ob- 






better down- 


strnction often 








wards than up- 


coexists, when 








wards. 


there is a dis- 
tinct double 
murmur heard 
over a large 
space. 




Presystolic. 


At or near 


Over the su- 


Murmur gen- 






the apex. 


perficial car- 
diac space 
only. 


erally rough, 
long, and loud, 
sometimes 
called "blub- 
bering ; " b e- 
ginning after 
the second 
sound and end- 


Mitral 








i n g abruptly 
with the first 


Obstruc- 








tion. 








sound. 
Weakened 


(Stenosis.) 








aortic second 
sound, and in- 


[4-] 






• 


tensified pul- 
monic second 
sound, the lat- 
ter owing to 
obstruction of 
the pulmonary 
circulation. 



OF DISEASES OF THE HEART. 89 

TABLE NO. 11. Continued. 



PERCUSSION. 



Great hypertrophy 
and afterwards dilata- 
tion of the left ven- 
tricle are induced. 
Therefore in the early 
part of the disease, 
the percussion signs 
of the former, and 
later those of both 
combined, will be 
found ; finally, if the 
patient lives long 
enough, only those of 
dilatation. 



Dilatation, and oft- 
en hypertrophy, of 
the left auricle is first 
produced, followed by 
hypertrophy of the 
right ventricle to over- 
come the pulmonary 
obstruction ; next, dil- 
atation of the right 
ventricle; next, dila- 
tation of the right au- 
ricle. 

Finally, not often, 
but exceptionally, hy- 
pertrophy or dilata- 
tion of the left ven- 
tricle. 

Percussion signs ac- 
cordingly. 



INSPECTION. 



See Left 
Heart Hy- 
pertr o p h y 
and Dilata- 



tion, 
dally 
latter. 



the 



See Right 
Heart Hy- 
pertr o p h y 
and Dilata- 
tion, espe- 
cially the 
latter. 



PALPATION. 



See Left 
Heart Hy- 
pert r o p h y 
and Dilata- 
tion, espe- 
cially the 
latter. 

Strong, 
jerking, ar- 
terial pulsa- 
tion felt in 
s u p e rficial 
arteries all 
over the 
body. 



See Right 
Heart Hy- 
pert r o p h y 
and Dilata- 
tion, espe- 
cially the 
latter. 

Distinct 
purring thrill 
over the 
apex, _ pre- 
systolic in 
time. 



REMARKS. 



Aortic regurgitation is 
more apt to induce mitral 
insufficiency than aortic 
obstruction is. 

In such cases there may 
coexist two, three, or even 
all four of the murmurs 
of the left side of the 
heart. 

There is generally nei- 
ther dropsy nor dyspnoea 
in aortic diseases, unless 
mitral regurgitation coex- 



Mitral obstruction is 
comparatively a rare dis- 
ease, and, when met with, 
is oftener found in con- 
nection with mitral regur- 
gitation than alone. Still 
it may exist without re- 
gurgitation. It is possible 
to have mitral obstruction 
without a murmur, if the 
curtains are not adherent 
at their sides ; and on the 
other hand, Flint says that 
there may be, rarely, a 
mitral direct murmur with- 
out obstruction when there 
is also free aortic regurgi- 
tation. 

The orifice is sometimes 
too small to admit the end 
of the little finger, whereas 
in health three fingers can 
be passed through it. 

There cannot be much 
mitral obstruction or re- 
gurgitation so long as the 
aortic and pulmonic second 
sounds preserve their nor- 
mal relative intensity. 



90 



THE PHYSICAL DIAGNOSIS 
TABLE NO. 11, Continued. 





AUSCULTATION. 


DISEASE. 












Rhythm of 


Maximum In- 
tensity of 
Murmur. 


Murmur 


Other things 




Murmur. 


also heard. 


to be noticed. 




Systolic. 


At or near 


Over the 


Murmur general- 




• 


the apex. 


s u p e rficial 
cardiac 
space ; and 
unless too 
feeble, in the 
left axilla 
and behind, 
near the 
lower ansjle 
of the left 
scapula. 


ly soft, but some- 
times rough or mu- 
sical. 

Aortic second 
sound weakened, 
but pulmonic sec- 
ond sound (heard 
in the second left 
intercostal space) 
often intensified. 

Where mitral ste- 
nosis and regurgi- 
tation coexist, there 
will be one continu- 
ous murmur, made 
up of two elements, 
presystolic and sys- 


Mitral 








tolic; the first of 


Regurgita- 








which will not be 


tion. 








conveyed to the left 
and back. Besides, 


(Insufficiency.) 








they almost always 
differ in pitch and 


[1-] 








quality. 



OF DISEASES OF THE HEART 
TABLE NO. 11, Continued. 



91 



PERCUSSION. 



The same 
changes take 
place as in the 
preceding ; and 
besides, there is 
always more or 
less hypertrophy 
or dilatation of 
the left ventricle. 

Percussion 
dullness increased 
in every direction. 



INSPECTION. 



Area of 
ible impulst 
creased. 



PALPATION. 



Impulse forci- 
ble or diffused 
according to the 
proportion of hy- 
pertrophy or dil- 
atation. 

Apex beat far- 
ther to the left 
than normal. 

If hypertrophy 
predominates, it 
will be lower 
than if dilatation 
predominates. 

Pulse variable 
in volume, and in 
the later stages 
also irregular in 
time. 



The commonest of 
all valvular diseases, 
especially among the 
young. It often ex- 
ists alone, but may 
have mitral obstruc- 
tion associated with it. 
It is almost invaria- 
bly attended by a 
murmur, but a mitral 
systolic non-regurgitant 
murmur may be pro- 
duced by simple 
roughening, c a 1 c a- 
reous deposit, etc., 
without insufficiency 
of the valve. The 
signs which especially 
distinguish the regur- 
gitant from the non-re- 
gurgitant murmur are 
the strong pulmonary 
second sound, the 
weak aortic second 
sound existing even 
with hypertrophy of 
the left ventricle, the 
diffusion of the mur- 
mur to the left side 
and to the back, and, 
after the disease has 
made some progress, 
the symptoms of pul- 
monary congestion. 

Dyspnoea and 
dropsy are prominent 
symptoms of mitral 
obstruction and re- 
gurgitation. 

Tricuspid regurgi- 
tation is often found 
as a secondary affec- 
tion in connection 
with mitral disease. 



92 



THE PHYSICAL DIAGNOSIS 
TABLE NO, 11, Continued. 





auscultation. 


DISEASE. 


Rhythm of 
Murmur. 


Maximum In- 
tensity of 
Murmur. 


Murmur also 
heard. 


Other things to 
be noticed. 


II. Right 
Heart. 

Pulmonic 
Obstruc- 
tion. 

(Stenosis.) 

[6.] 


Systolic. 


Second or 
third left in- 
ter costal 
space, near 
the sternum. 


Propagated 
upwards for 
a short dis- 
t a n c e to- 
wards the 
left clavicle, 
but not over 
the aorta or 
carotids. 

Remember 
that excep- 
tionally an 
aortic ob- 
structive 
murmur 
man be heard 
with great- 
est intensity 
at the second 
or third left 
i n t ercostal 
space. The 
frequency of 
the aortic 
murmur 
and its other 
charact e r s 
will gener- 
ally suffice 
for a diag- 
nosis. 


Second pulmonic 
sound impaired in 
intensity. 

Murmur super- 
ficial and may be 
quite intense. Must 
be diagnosticated 
from the inorganic 
pulmonic murmur, 
which is far more 
common than the 
organic, either 
alone or with the 
other inorganic 
m u r m u r — the 
aortic direct. 

Inorganic mur- 
murs are always 
systolic, and almost 
never occur except- 
ing at the aortic and 
pulmonic orifices. 

T h e inorganic 
murmur is soft and 
feeble, with normal 
heart sounds and 
no enlargement, not 
constant, occurs in 
anaemic persons, es- 
pecially young fe- 
males, and is ac- 
companied by the 
bruit de diable. 


Pulmonic 
Regurgita- 
tion. 

(Insufficiency.) 
[7-] 


Diastolic. 


Second or 
third left in- 
tercostal 
space, near 
the sternum. 


Propagated 
down war d s 
towards the 
ensiform 
cartilage. 


Pulmonic second 
sound impaired in 
intensity. 

This murmur, if 
it were more com- 
mon, might easily 
be confounded with 
an aortic regurgi- 
tant murmur, when 
the pulmonary di- 
rect murmur did 
not co-exist. 



OF DISEASES OF THE HEART. 
TABLE NO. 11, Continued. 



93 



PERCUSSION. 



Hypertrophy 
and dilatation of 
the right ventri- 
cle are produced. 

Percussion 
signs accordingly. 



Theoretically, 
hypertrophy and 
dilatation of the 
right ventricle 
are produced. 

Percussion 
signs accordingly. 



INSPECTION. 



See Hyper- 
trophy and Dil- 
atation of the 
Right Ventricle. 



See Hyper- 
trophy and Dil- 
atation of the 
Right Ventricle. 



PALPATION. 



See Hyper- 
trophy and Dil- 
atation of the 
Right Ventricle. 



See Hyper- 
trophy and Dil- 
atation of the 
Right Ventricle. 



Valvular diseases of 
the right heart, with 
the exception of tri- 
cuspid regurgitation, 
are so infrequent as 
to be almost unheard 
of ; so much so, that 
when the unqualified 
term " valvular dis- 
ease " is used, the left 
heart is always meant. 

When right-heart 
lesions exist, they are 
usually, but not inva- 
riably, associated with 
left-heart lesions, un- 
less they are congen- 
ital. 

Contrary to the rule 
which prevails after 
birth, the right heart 
is more commonly af- 
fected in prsenatal life 
than the left. 



Pulmonic regurgi- 
tation is exceedingly 
rare, even more so 
than pulmonic ob- 
struction. Conse- 
quently, the annexed 
physical signs of it 
are, to a great extent, 
theoretical. 

Tricuspid insuffi- 
ciency may follow 
pulmonic obstruction 
or regurgitation. 



94 



THE PHYSICAL DIAGNOSIS 
TABLE NO. 11, Continued. 







AUSCULTATION. 














Rhythm of 
Murmur. 


Maximum In- 
tensity of Mur- 
mur. 


Murmur also 
heard. 


Other things to be 
noticed. 


Tricuspid 


Presystolic. 


At lower 






Obstruction. 




part of ensi- 
i'orm carti- 






(Stenosis.) 




lage. 






[8.] 












Systolic. 


At lower 


Generally 


A murmur is not 






part of ensi- 


limited to 


present in many 






form carti- 


the superfi- 


cases of actual tri- 






lage. 


cial cardiac 
space. 


cuspid regurgita- 
tion, even when 


Tricuspid 






If trans- 


there is a definite 


Regurgita- 






mitt ed at 


valvular lesion. 


tion. 






all, it is to 
the right. 


Rarely, if ever, 
rough. 


(Insufficiency.) 








Pulmonic second 
sound diminished in 


[5.] 








intensity. Mitral 
or aortic murmurs, 
or both, often coex- 
ist, differing in pitch 
and quality. 



OF DISEASES OF THE HEART. 95 

TABLE NO. 11, Continued. 



PERCUSSION. 


INSPECTION. 


PALPATION. 


- REMARKS. 


Theoretically, 
hypertrophy and 
dilatation of the 
right auricle are 
first produced. 






The rarest of alL 


First the right 
auricle is dilated, 
then the right 
ventricle is hy- 
pertrophied and 
dilated. Then 
comes enlarge- 
ment of the left 
ventricle on ac- 
count of its in- 
creased work. 

Per c u s s i o n 
signs accord- 
ingly 


Jugular p u l- 
sation, synchro- 
nous with the 
heart's systole, — 
a characteristic 
sign of tricuspid 
regurgi t a t i o n, 
unless the right 
ventricle be very 
weak from dila- 
tation. 

Larger area of 
visible impulse 
than with any 
other valvular 
lesion. 


Indistinct apex 
beat unless there 
is considera b 1 e 
hypertrophy o f 
the left ventricle. 
Distinct e p i- 
gastric p u 1 s a- 
tion. 


Primary tricuspid 
regurgitation is very 
rare; but secondary 
to mitral stenosis or 
regurgitation, it is 
not uncommon. 

It not infrequently 
exists in cases where 
there is no definite le- 
sion of the valve, but 
where, on account of 
enlargement of the 
right heart from mit- 
ral disease, the tricus- 
pid orifice is enlarged 
without a proportion- 
ate enlargement of 
the valve. 



96 



THE PHYSICAL DIAGNOSIS 
TABLE NO. 11, Continued. 



Fatty Degen- 
eration of the 
Heakt. 



Cakdiac Neuro- 
ses. 

(Nervous or func- 
tional disorders of 
the heart.) 



AUSCULTATION. 



Both heart sounds are per- 
manently weakened, especially 
the first. The second sound 
over the apex is clearer and 
louder than the first. First 
sound often absent. When 
present, it is short and valvu- 
lar, the muscular element or 
element of impulsion being 
greatly impaired. This con- 
dition is persistent, not tempo- 
rary ; and several examina- 
tions must be made before de- 
ciding on the diagnosis. 



Heart sounds healthy in 
quality, but intensified, clearer, 
and more abrupt than normal. 
Occasionally the first sound is 
metallic, and either may be re- 
duplicated. 

An inorganic anaemic mur- 
mur is sometimes heard at the 
base of the heart. It is systolic, 
either aortic or pulmonic or 
both, soft and feeble, often 
propagated into the carotids, 
and accompanied by a hum in 
the veins of the neck. 



percussion. 



Normal area of dullness 
as a rule. 

Sometimes a dilated or 
hypertrophied heart un- 
dergoes fatty degenera- 
tion, when, of course, its 
increased area of dullness 
will remain. 



Percussion dullness nor- 
mal. 

As a mere coincidence, 
functional disease may ex- 
ist in a hypertrophied 
heart. 



OF DISEASES OF THE HEART. 
TABLE NO. 11, Continued. 



97 



INSPECTION. 



No visible im- 
pulse as a rule, 
even in thin per- 
sons. 

If there is any, 
it is very indis- 
tinct. 



Increased area 
of visible im- 
pulse, which may 
be seen to be ir- 
regular and in- 
termit tent at 
times. 



PALPATION. 



Very little or no apex 
beat can be felt. If felt 
it is generally in its nor- 
mal position, and is irreg- 
ular or intermittent. 

If a hypertr o p h i e d 
heart becomes fatty, there 
is a tumbling, rolling mo- 
tion. 



Apex beat in normal po- 
sition. 

Increased action, not 
power. Beat abrupt and 
brief. A violent blow, 
not a powerful heaving. 

Sometimes impulse 
weaker than natural. 



Valvular lesions may co-exist. 
The diagnosis of fatty de- 
generation of a hypertrophied 
heart is very difficult. 



The physical signs are both 
negative and positive, — nega- 
tive in excluding all organic 
disease, and positive in show- 
ing the healthy size, position, 
and sounds of the heart. 

Patients with functional dis- 
ease complain much more of 
heart symptoms than those with 
organic disease. Inorganic pal- 
pitation is increased by seden- 
tary life, organic by exercise. 



